A comprehensive Oral Health Initiative for India & Developing Countries.

PREFACE:                                                                                            Dental diseases are a significant public health burden in India, with dental caries affecting 60 to 65 % and periodontal diseases affecting an estimated 50 to 90 % of the general population, depending on age, with research suggesting that higher rates of dental diseases occur in Rural areas.

                      The consequences of widespread poor oral health can be seen on the personal, population, and health systems level, as caries and periodontal disease deteriorate individual health and well being, decrease economic productivity, and act as significant risk factors for other systemic health ailments.

                   Oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world. The greatest burden of oral diseases is on disadvantaged and socially marginalized populations.  

Dental diseases in rural India are primarily due to socio-cultural factors, such as inadequate or improper use of fluoride products and a lack of knowledge about oral health and hygiene, and systemic infrastructure deficiencies that prevent proper screening and dental care of oral diseases, especially in rural areas.

BACKGROUND:

The World Health Organization defines oral health as 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”.

 Of all these, Dental caries is the most common non-communicable disease in the world (Beaglehole, et al., 2009); periodontal disease and dental caries are the two dominant disease burdens in oral health (Petersen & Ogawa, 2005). Both can be attributed to the formation of plaque, a sticky biofilm that adheres to teeth and is comprised mostly of four components: (1) bacteria in the oral cavity used to convert food into acids, (2) acid, (3) food debris, and (4) saliva (Bratthall, Petersen, Stjernsward, & Brown, 2006). If dental plaque is not removed thoroughly and frequently, the acid created by the bacteria begins to cause localized dissolution of the tooth’s hard tissues such as enamel, dentin, and cementum, which results in tooth damage. As this process occurs over time, Dental carries will form (Bratthall, et al., 2006).

Additionally, if dental plaque is not removed, the biofilm will also mineralize into tartar – also known as calculus – which, along with the plaque, acts as an irritant on the gums. This irritation results in gingivitis, an inflammation or infection of the gums. If left untreated, gingivitis ultimately causes periodontal disease, which occurs when the infection spreads to the ligaments and bone that supports the teeth (Rosenberg, 2010). Both dental caries and periodontal disease can cause reduced quality of life and diminished function as a result of the pain and suffering associated with oral conditions (Petersen, 2003).

The need to address these oral health concerns is especially evident in India because Dental caries affects 60 to 65 per cent of the general population (Kaur, et al., 2010). Additionally, Periodontal disease is estimated to occur in 50 to 90 per cent of the population in India, depending on age (Agarwal, Khatri, Singh, Gupta, Marya, & Kumar, 2010; Kaur, 2009).

While these statistics reveal a deficiency in dental care for all of India, it can be posited that Oral Health in Rural villages is in more dire conditions than urban areas because rural areas in India are more susceptible to dental caries and periodontal disease, in part because rural villages have lower access to preventative and restorative dental care (Goldman, Yee, Holmgren, & Benzian, 2008).

Thus, this intervention plans through the opening up of Rural Dental Centers in the villages to increase awareness of the importance of Good Oral Habits and improving access to Dental Services in Rural India.

A.EPIDEMIOLOGY OF ORAL DISEASE:

Beyond prevalence, oral health status is often characterized with the DMFT index, which sums the number of Decayed, Missing, and Filled Teeth within a person’s mouth (Hussain & Chockalingam, 2009).

In India, dental caries directly affects around 60% of the population (Shah, 2005; Kaur, et al., 2010). The prevalence of dental caries is positively correlated with age (Agarwal, et al., 2010). A 2004 survey found that the prevalence of dental caries in children aged five years was 50%; 52.5% in 12 year-olds; 61.4% in 15 year-olds; 79.2% in 35-44 year-olds; and 84.7% in 65-74 year-olds (Bali, Mathur, Talwar, & Chanana, 2004).

The World Dental Federation estimates that 83% of children aged 6-19 years have dental caries (FDI World Dental Federation, 2011). The majority of 12 and 15 year-olds had a DMFT value between 1-3, while the majority of older adults (65-74 years) had a DMFT value between 25-32 (Bali, et al., 2004). In 12 year-olds, the average DMFT value was 1.7 (Bali, et al., 2004). The same 2004 survey by Bali, et al. found no gender difference in the prevalence of dental caries, but there was a higher prevalence of dental caries in rural populations as compared to urban.

Periodontal disease affects the majority of Indians and follows a similar trend as dental caries, where the prevalence increases as age increases. In 12 year-olds, the prevalence was 55.4%, increasing to 89.2% of 35-44-year-olds (Bali, et al., 2004). The prevalence in the 65-74 age range was slightly lower (79.4%), most likely due to the high prevalence of missing teeth in this age range (Bali, et al., 2004). Periodontal disease is equally prevalent across genders, with somewhat higher prevalence in rural areas (Bali, et al., 2004).

B. POLICY BASIS FOR THE WHO ORAL HEALTH PROGRAMME:

1.Oral health is integral and essential to general health:

Oral health means more than good teeth; it is integral to general health and essential for well-being. It implies being free of chronic oro-facial pain, oral and pharyngeal (throat) cancer, oral tissue lesions, birth defects such as cleft lip and palate, and other diseases and disorders that affect the oral, dental and craniofacial tissues, collectively known as the craniofacial complex.

2.Oral health is a determinant factor for quality of life :

The craniofacial complex allows us to speak, smile, kiss, touch, smell, taste, chew, swallow, and to cry out in pain. It provides protection against microbial infections and environmental threats. Oral diseases restrict activities in school, at work and at home causing millions of school and work hours to be lost each year the world over. Moreover, the psychosocial impact of these diseases often significantly diminishes the quality of life.

3.Oral health – General health:

Oral health is integral to general health. Periodontal disease, for example, is associated with general health conditions such as cardiovascular disease and diabetes. Those with complex health conditions are at greater risk of oral diseases.  

 The strong correlation between several oral diseases and noncommunicable chronic diseases ( NCDs ) is primarily a result of the common risk factors. Many general disease conditions also have oral manifestations that increase the risk of oral disease which, in turn, is a risk factor for a number of general health conditions.

Some general health diseases manifest in the mouth, and oral lesions may be the first signs of other life-threatening diseases such as HIV/AIDS.

Poor oral health can have a profound effect on the quality of life. The experience of pain, the endurance of dental abscesses, problems with eating and chewing, embarrassment about the shape of teeth or about missing, discoloured or damaged teeth can adversely affect people’s daily lives and well-being.

General health risk factors such as excessive alcohol intake, smoking or other tobacco use and poor dietary practices also affect oral health.

4.Proper oral health care reduces premature mortality:

Early detection of disease is in most cases crucial to saving lives. A thorough oral examination can detect signs of nutritional deficiencies as well as a number of general diseases including microbial infections, immune disorders, injuries, and oral cancer. The craniofacial tissues also provide an understanding of organs and systems in less accessible parts of the body.

5.Oral Disease and its Impact Worldwide:

Despite great achievements in the oral health of populations globally, problems still remain in many communities around the world – particularly among underprivileged groups in developed and developing countries. Dental caries and periodontal diseases have historically been considered the most important global oral health burdens. At present, the distribution and severity of oral diseases vary in different parts of the world and within the same country or region. The significant role of socio-behavioural and environmental factors in oral disease and health is demonstrated in a large number of epidemiological surveys.

In many developing countries, access to oral health services is limited and teeth are often left untreated or are extracted because of pain or discomfort.

While oral and pharyngeal cancers are both preventable, they remain a major challenge to oral health programmes. The prevalence of oral cancer is particularly high among men, the eighth most common cancer worldwide (Incidence rates for oral cancer vary in men from 1-10 cases per 100 000 inhabitants in many countries. In south-central Asia, cancer of the oral cavity ranks amongst the three most common types of cancer. In Asia, the age-standardized incidence rate of oral cancer per 100 000 population ranges from 0.7 in China to 4.6 in Thailand and 12.6 in India. The high incidence rates relate directly to risk behaviours such as smoking, use of smokeless tobacco (e.g. betel nut or miang chewing) and alcohol consumption.

C. DETERMINANTS:

a.Diet & Nutrition:

Increased rates of gingivitis, dental caries, and periodontal disease traditionally follow rising economic development because, as economies expand in developing countries, the populations within these countries have access to a wider variety of food as a result of increased income and trade. Thus, as countries become wealthier, there is more exposure to, and an increased preference for, a “westernized” diet that is high in carbohydrates and refined sugars (Goldman, et al., 2008). This change in dietary patterns influences oral health because chronic dental diseases are strongly related to diets rich in saturated fatty acids and non-milk extrinsic sugars (Petersen & Ogawa, 2005).

India has demonstrated a marked increase in sugar consumption in recent years, as per capita consumption was 13.8 kilograms in 1991, 16.5 kilograms in 2000, and 19.6 kilograms in 2005 (World Health Organization, 2011). This shows that an increasing consumption low nutritional value foods, or “junk” foods, and refined sugars in the form of chocolates and other sticky sugar-rich foods, especially in younger generations, may be contributing to an increase in dental caries and periodontal diseases (Kaur, et al., 2010; Khan, Jain, & Shrivastav, 2008).

Diet and nutrition affect oral health in many ways. Dental diseases related to diet include dental caries, developmental defects of enamel, dental erosion and periodontal disease.

b. Fluoride Exposure:

While an increase in the consumption of refined sugars has contributed to the prevalence of dental diseases in India, this determinant alone is an insufficient explanation because research evidence has demonstrated that proper oral hygiene practices with fluoride-supplemented products can mitigate the detrimental oral health effects of sugar consumption.

Therefore, the cariogenic potential of diets high in sugar emerges mostly in areas where fluoride supplementation is inadequate or improperly used (Goldman, et al., 2008). Sodium fluoride is available in a number of supplemental forms including fluoridated drinking water, fluoridated salt, fluoridated milk, fluoridated varnish, and fluoridated toothpaste (Petersen & Lennon, 2004).

However, research has indicated that, in the rural villages, fluoridated toothpaste is the only product readily available, and the beneficial effects of using fluoridated toothpaste for oral health are optimized if brushing is performed twice a day, using proper brushing technique, because this maintains a consistent low concentration of fluoride in the oral cavity (Marinho, Higgins, Logan, & Sheiham, 2009).

However, field research has observed that the vast majority of rural villagers surveyed only cleaned their teeth once a day. Thus, it is evident that a lack of use and improper use of fluoridated toothpaste both contribute to the high level of dental diseases observed in the villages and the rest of rural India.

However, populations in many developing countries do not have access to fluorides for prevention of dental caries for practical or economic reasons. One of WHO’s policies is to support the widespread use of affordable fluoridated toothpaste in developing countries. This is particularly important in light of the changing diet and nutrition status in these countries. Recent local studies have shown that affordable fluoridated toothpaste is effective in caries prevention and should be made available for use by health authorities in developing countries.

c.Knowledge & Hygiene Habits:

Effective oral hygiene practices have been well established in developed countries. However, oral hygiene practices in India indicate that there is still a lack of knowledge about proper oral hygiene. This is demonstrated by a 57% usage rate of toothbrushes and only 40% use of fluoridated toothpaste in the rural areas, with higher rates of usage reported in urban areas (Bali, Aswath, et al., 2004). This implies that toothbrush and fluoridated toothpaste usage in rural areas are considerably lower.

Additionally, as noted earlier, it has been observed to be common practice in rural villages to only brush once a day, rather than the widely-recommended twice a day brushing patterns utilized in developed countries. Field observations have also indicated a lack of oral health education in primary and secondary schools in the villages and a general lack of oral health knowledge within the community.

 These observations support academic claims that mass awareness of oral health practices is very low in India, especially in rural communities which tend to place low importance on oral hygiene (Kaur, 2009).

There also seems to be a general lack of awareness about oral health in general among residents living in rural areas. The majority of residents (55%) were aware of neither factors that could cause oral health problems nor any preventative measures that could be taken to prevent oral health issues (Bali, Aswath, et al., 2004).

d.Access to Care:

In rural India, the dentist to population ratio can be as high as one dentist for every 250,000 residents, while the ratio is estimated at one dentist to every 10,000 in urban areas (Tandon, 2004). At the same time, 72.2% of the population in India resides in rural areas (Saravanan, et al., 2008). In comparison, the Henry J. Kaiser Family Foundation estimates there to be one dentist per every 1,250 residents in the United States (2009).

 The low number of dentists in rural areas, a distribution perpetuated by the current landscape of professional oral health training, is a significant barrier to access for rural village residents.

India in the last financial budget ( 2015-2016) spent just 4.2% of its GDP on Healthcare, of which Public Health spending was a mere 1.2%. Surprisingly, no government funds were specifically designated for oral health care. Lately, the Government of India has rechristened Oral Health as the National Oral Health Programme ( NOHP ) and brought it under the purview of National Health Mission ( NHM ) for Funding.

The Government of India has now decided that National Oral Health Program (NOHP), would be a part of Health system strengthening under NRHM (also known as Mission Flexible pool). Approvals will be given to the states in NOHP under Health system strengthening under NRHM. The Utilization Certificate(UC)under the pool of system strengthening will cover the utilization of NOHP.

The most accessible and principal healthcare provision facilities for Rural India, Primary Health Centers (PHC), do not provide Dental Services, and only 20-25% of Community Health Centers, the point of secondary healthcare for Rural villages within the Indian healthcare system, provide Dental Care (Agarwal, et al., 2010; Tandon, 2004).

That public spending is not meeting people’s health care expenditure needs is evident from out-of-pocket-expenditure data compiled by the World Bank. In the year 2014-’15, 62.42% of health spending was borne by citizens. Ideally, when a country’s public healthcare system is improving, the out-of-pocket-expenditure as a percentage of total health expenditure should come down. In India’s case, it only has reduced marginally, from 63.37% in 2010 to 62.4% in 2015.

e.Substance Use:

Tobacco is generally accepted to be a harmful substance; its use has been correlated to numerous diseases, including coronary heart disease, respiratory diseases, diabetes, ulcers, and many forms of cancer, including oral, lung, kidney and pancreas (Petersen & Ogawa, 2005).

 Additionally, it has significant effects on the oral health of users. Tobacco use is associated with heightened periodontal breakdown, poorer standards of oral health and subsequent premature tooth loss (Petersen, et al., 2005). In periodontal disease, smoking has been identified as a major risk factor and, among United States adults, is potentially responsible for more than 50% of periodontal disease cases (Tomar & Asma, 2000).

Smoking is the most significant modifiable risk factor for periodontal disease (Johnson & Guthmiller, 2007). Chewing tobacco is also a significant risk factor correlated with gingival inflammation and periodontal disease (Winn, 2001). Both the use of chewing tobacco and smoking cigarettes are risk factors in the development of caries (Tomar & Winn, 1999; Campus, Cagetti, Senna, Blasi, Mascolo, Demarchi & Strohmenger, 2011). Chewing tobacco is especially significant, as its contents include a high proportion of sugar (Winn, 2001).

 Finally, tobacco use is highly correlated with the presence of oral cancer, with 95% of oral cancers directly related to tobacco use (Winn, 2001; Shah, 2005). The use of tobacco has a clear impact on a person’s oral health status.

Tobacco use is a major preventable cause of premature death and of several general diseases. In addition, cigarette, pipe, cigar and bidi smoking, betel quid chewing (pan), gutka use and other traditional forms of tobacco have several effects in the mouth. Tobacco is a risk factor for oral cancer, oral cancer recurrence, adult periodontal diseases and congenital defects such as cleft lip and palate in children.

Tobacco suppresses the immune system’s response to oral infection, compromises healing following oral surgery and accidental wounding, promotes periodontal degeneration in diabetics and adversely affects the cardiovascular system.

D.BURDEN OF ORAL DISEASE:

As described, dental diseases are very prevalent in India, and this high prevalence has led to a substantial burden on individuals, communities, and the healthcare system. On a personal level, dental caries and periodontal diseases have a significant negative influence on the quality of life in both children and adults due to deteriorations in an individual’s general health and development (Goldman, et al., 2008).

 By crippling the functionality of the oral cavity, dental diseases, combined with limited food variety and accessibility in rural villages, also causes malnutrition in adults, as severe pain due to untreated caries and periodontal disease incapacitates an adult’s ability to chew coarse food (Shah, 2005; Bali, et al., 2004).

Given the extent of the problem, oral diseases are major public health problems. Their impact on individuals and communities, as a result of pain and suffering, impairment of function and reduced quality of life, is considerable. The four most prominent NCDs – cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases share common risk factors with oral diseases.

The widespread nature of dental diseases in rural India means that the detrimental effects of caries and periodontal disease within the individual will also have a negative impact on the functioning of a population. Evidence of this can be found in a study conducted by the National Council on Macroeconomics and Health (NCMH) in India. Within this study, the NCMH identified oral diseases as one of seventeen priority health conditions they considered to be serious public health problems.

Oral diseases were identified as one of these priority health conditions because, in late stages, dental caries and periodontal diseases cause severe pain and are expensive to treat (National Council on Macroeconomics and Health, 2005). This translates into a loss of man-hours which has a significant negative impact on economic productivity (Shah, 2005 & Goldman, et al., 2008). Finally, in terms of disability-adjusted life years (DALYs) lost, oral diseases represented 0.5% of India’s total disease burden – with 1,247,000 total DALYs lost in 1998 – and this number was projected to increase by 25% in the decade following the study (Peters, Yzbeck, Ramana, Sharma, Pritchett, & Wagstaff, 2001).

As noted earlier, there is insufficient infrastructure for providing dental care in rural India. Nonetheless, the treatment of dental diseases is traditionally very costly worldwide, representing the fourth most expensive set of diseases to treat in industrialized countries with advanced oral health systems that offer curative services to patients (Petersen, Bourgeois, Ogawa, Estupinan-Day, & Ndiaye, 2005).

 In developing countries such as India, there has been very little investment in oral healthcare and resources are primarily allocated only to emergency care and pain relief. However, if advanced systems of curative care were in place in India, the costs of treating dental caries in children alone would exceed the total annual healthcare budget allocated for child health (Petersen, Bourgeois, Ogawa, Day, & Ndiaye, 2005).

In addition to the direct burden oral diseases would place on a health infrastructure, if a comprehensive one were in place, Dental caries and Periodontal disease also place additional burdens on traditional medical healthcare systems. This is because, if left untreated, the chronic inflammation and inflammatory mediators associated with dental diseases are a significant risk factor for several systemic diseases. These include the,

 1. Birth of pre-term low-birth-weight babies,

2. Coronary artery diseases, and

 3. Diabetes mellitus (Agarwal, et al., 2010).

The impact of untreated dental diseases on maternal and child health is especially disconcerting, as pregnant women suffering from periodontal disease are seven times more likely to give birth to a pre-term low-weight baby, even when controlling for other factors (Center for Global Development, 2007).

E. EFFORTS TO MITIGATE DISEASE BURDEN:

Current Efforts:

Nationally, the Indian Government has been taking steps over the last 20 years to begin addressing the oral health of its population. In 1995, an Oral Health Policy was accepted as part of a National Health Policy during the Fourth Conference of Central Council of Health & Family Welfare (Kishor, 2010). Contained within this policy were a set of nationwide goals similar to the goals World Health Organization crafted in 1979 (Lal, Paul, Pankaj, Vikas, & Vashisht, 2004):

For the new millennium, new oral health goals are urgently needed not only to strengthen dental caries control and prevention activities, but also to address other significant components of the oral disease burden such as periodontal health conditions, oral mucosal lesions, oral pre-cancer and cancer, craniofacial trauma, pain, and oral health-related quality of life. Such global goals for oral health will assist regions, countries and local health care planners to develop preventive programmes that are targeted at populations and high-risk groups and to further improve the quality of oral health systems.

In order to reach these goals,, the National Oral Health Care Programme was established in 1998, targeted at providing oral health care through primary prevention and strengthening existing oral health care set up (Kishor, 2010). The strategies contained within the Programme primarily focus on prevention such as education and screening, as well as proposed mobile oral clinics and a nationwide oral health surveillance system (Kishor, 2010; Pandve, 2009).

The focus on primary and secondary prevention stems from an acknowledgement that there is a lack of basic oral health care facilities nationwide (Srivastava, 2009). Since the acceptance of this policy, the government has been working to determine how to implement these strategies; pilot programs have been focused on North-Eastern states (Pandve, 2009). Given the expensive nature of treating oral and dental conditions, the government has chosen to focus on developing primary prevention strategies, with the belief that it will be more impactful with few resources (Srivastava, 2009).

Among non-governmental organizations, dental screening camps are a popular method to address oral health. These screening camps traditionally offer dental screening with a referral for dental services, occasionally coupled with oral hygiene education.

F.BARRIERS TO DISEASE MITIGATION EFFORTS:

Currently, all existing efforts address one portion of the continuum of care – primary, secondary, or tertiary – without confronting the entire continuum. As previously discussed, there are significant barriers to accessing dental services in India, which mainly include the following:

 a. high cost for services,

b. long travel to reach a dentist,

c. extremely low dentist to population ratio.

          Because of these barriers, screening programs alone are not comprehensive enough to have any significant impact on the prevalence of oral health in India. Identifying cases of poor oral health without providing any follow-up care, or providing a referral for a treatment that is both far away and expensive, simply raises the prevalence of disease, as more cases will be identified through screening. Additionally, it is unethical to identify the disease in a person when treatment is not accessible (Shickle & Chadwick, 1994). For these reasons, screening alone simply cannot begin to address oral health in India.

Oral health has been an area of focus for government officials in India for almost fifteen years. However, in that time, much of the work that has been accomplished has been formative research, with pilot programs as the bulk of programming that has been implemented (Pandve, 2009).

While pilot programs are a necessary part of program development, the pilots have been concentrated in the North-Eastern states of India; residents of those states may have benefited from the programs, but as no nation-wide programs have been implemented, no nation-wide effects have been documented (Kishor, 2010).

Additionally, the focus of the government has been on preventative care, which, while a crucial portion of oral health care, is simply not enough to impact the general oral health of a population when access to curative treatment is so challenging. In order to have a significant impact on oral health, a comprehensive plan is necessary, in which primary, secondary and tertiary prevention and care are integrated into a multi-faceted intervention.

G.ORAL HEALTH INTERVENTION & IMPLEMENTATION:

It has been established that rural India is experiencing wide-spread challenges in oral health. It can be further said that these challenges exist at every level of the healthcare infrastructure, from a lack of dissemination about preventative oral health education to severely restricted access to curative dental treatments.

Accordingly, this intervention is designed to comprehensively address these challenges, through the implementation of an intervention that delivers primary, secondary, and tertiary level prevention.

 The primary prevention strategy is a school-based oral health promotion program, including behavioral oral hygiene education and the provision of fluoride-supplemented oral health products.

 The implementation of a comprehensive screening program is the secondary prevention strategy, and improving access to professional curative dental care is the health intervention proposed as a tertiary prevention strategy.

1.PRIMARY PREVENTION:

Oral Health Education:

The primary component of this intervention is a school-based oral health promotion program.  A school-based intervention was selected because, in rural areas of developing countries such as India, a considerable number of children and their parents lack knowledge about the causes of oral diseases and methods available to prevent them. Additionally, schools provide an effective platform for disseminating and reinforcing this information throughout the school years, which are the life-stages where lifelong beliefs, attitudes, and skills are developed (Kwan, Petersen, Pine, & Borutta, 2005). Schools in India are an ideal platform for oral health promotion programs because India possesses one fifth of the world’s children and the majority of young children in India are in primary school, with a 91% male and an 88% female enrollment rate (Joshua, 2009; United Nations Children’s Fund, 2011). School-based health promotion programs have the additional benefit of also improving the health of school staff, families, and community members through exposure to information and behavioural skills (Kwan et al., 2005).

This school-based oral health promotion program will include:

1.an oral health education component with two lessons covering (i) the aetiology of caries and periodontal diseases and (ii) proper oral hygiene behaviours; and

2.supervised provision of a biweekly fluoridated mouth rinse.

The two lessons will be conducted via multimedia presentations, such as video recordings or audiovisual aids for a greater impact on the children and the teachers.

b.Fluoride Rinse:

Fluoride supplementation was chosen as a component of this oral health promotion program because it has been well-established through research that fluoride is the most effective method of dental caries prevention, especially when a low level of fluoride is constantly maintained in the oral cavity, and fluoride therapies have successfully been the cornerstone of caries-preventative strategies for the past five decades, even more so in areas where sugar consumption is high or increasing (Petersen & Lennon, 2004).

The use of fluoride supplementation as a mechanism of preventative oral health is also widely considered to be more cost-effective than providing curative treatments after dental diseases have manifested (Marinho et al., 2009). The anti-caries effects of fluoride are considered to result mostly from the action of fluoride on the tooth/plaque interface, where it promotes the remineralization of early caries lesions and reduces tooth enamel solubility to corrosive acids (Marinho et al., 2009).

The components of this oral health promotion program will be operationalized through two activities: oral health education and a regular fluoride rinse.

2.SECONDARY  PREVENTION:

Secondary prevention occurs when a disease is present, but the illness is not yet being experienced by the individual. This level of prevention is particularly important in oral health, as dental caries and periodontal disease are often initially asymptomatic and continue to have minimal symptoms until progressing to the point at which the disease is severe and the symptoms have a significant impact on quality of life (Goldman, et al., 2008; Petersen, 2003). Given this progression, a screening program – to identify dental caries and periodontal disease – is a necessary component of this intervention. The screening portion of this intervention plan will be integrated at every level of care.

i.Screening:

The goal of the oral cavity screening is to be comprehensive, not only in the oral conditions screened, but also in its penetration of the population.

ii.School Screening:

In addition to the Oral Health Screening Protocol being implemented population-wide, the screening will also occur at the schools. This screening will occur once at the beginning of each semester. Ideally, screening should occur on the same day as the first fluoride rinse and oral health education video, for greater impact. This screening should first utilize the non-invasive oral health screening instrument, with an immediate follow-up comprehensive screening occurring that same day at the school.

This secondary prevention portion of this intervention aims to ensure screening of an entire population, recognizing that oral disease is not specific in the demographic that it affects.

3.TERTIARY PREVENTION:

Access to dental care is a significant determinant in the poor oral health status of rural populations in India. This was demonstrated through the experiences of those in villages, as the absence of a dentist in the village and the long travel time associated with seeking the services of a dentist in Cities both affect the ability of village residents to access proper dental care. The tertiary component of this intervention is aimed at increasing access by minimizing the barriers to care. This component is necessary to create a continuum of care; additionally, with the secondary prevention intervention proposed, it is ethically necessary to increase access to care when implementing a screening program in order to provide both follow-up and care for individuals with oral conditions identified by the screening.

This strategy will be operationalized through two activities:

(1) ensuring the presence of a trained dental professional in the Rural Dental Centers, on a permanent basis, and

 (2) equipping each Rural Dental Center with the dental equipment necessary to perform basic preventative and curative dental treatments.

a.Dental Care Provider:

As previously discussed, populations living in rural areas in India have very little access to dental care providers, with a trip to the dentist taking an entire day. In order to minimize this barrier, this intervention aims to recruit Dental Professionals willing to serve in the Rural Dental Centers on a permanent basis.

b.Equipment:

In order for any dental care to occur at the Rural Dental Center, it is necessary to procure and install dental equipment in each Rural Dental Center. Therefore, even for the visiting dentists, it is necessary to have dental equipment in the Rural Dental Clinic.  At the very least, a dental chair and basic scaling tools will be required.

G.RECOMMENDATIONS FOR THE FUTURE:

Though there are several current challenges to addressing dental diseases in villages, these limitations also shine light on possible future efforts that could more comprehensively address oral health in rural areas. In the area of oral health education, if the simple, two lesson curriculum utilized in schools is demonstrated to be effective, Rural Dental Centers could begin to offer bi-weekly or monthly oral health education sessions for the general public utilizing the same learning materials.

a. Because fluoridated toothpaste is a highly effective means of caries control, every effort must be made to develop affordable fluoridated toothpaste for use in developing countries. The use of fluoride toothpaste being a public health measure, it would be in the interest of countries to exempt them from the duties and taxation applied to cosmetics.

b. Salt fluoridation as a means of population-wide fluoride supplementation should be considered. This method of salt fluoridation could be easily implemented across the rural hinterland in India as a low economic cost to the Governments especially targetting the rural people in the prevention of caries.

Pursuing a fluoride supplementation program of this type is being recommended because it has been demonstrated to be cost-effective and beneficial. An example of this is the salt fluoridation program that occurred in Jamaica in the early 1980s. By 1995, the index of caries severity in this country had fallen by more than 80% in children and the salt fluoridation only cost 6 cents per person (Center for Global Development, 2007).

H.CONCLUSION:

Unhealthy dietary habits, smoking and other tobacco use, alcohol consumption and stress are some of the common risk factors for many NCDs, including oral health. While there has been encouraging improvement in oral health in many countries over the past few decades, much work remains to be done. With many challenges ahead, it is important to build on our achievements, and on strategies that work.

Some countries should reorient their existing investments in health, to reflect the varying needs of a diverse population. Healthy public policies are fundamental to improving access, promoting equity and creating supportive environments.

 Public accountability for health can be a driving force for change, a vital element in the advancement of healthy public policies. In order to build effective partnerships for health development and to form healthy alliances, global, national and local commitment is critical.

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Fluorides in Dentistry: One of the ten most important public health measures of the 20th Century.

Abstract:

The nature of dentistry for children changes greatly with water Fluoridation and topical fluorides are used as a means of preventing dental caries. The effects are lasting and persist into adulthood; therefore the dental health of the community takes on a new perspective.

The approach of Dentists, Dental Auxiliaries and Dental Students should be towards Preventive Dentistry.

 Use of Fluoridation of the water supply of 1 part per million ( ppm ) Fluoride level has shown a reduction of dental caries to the extent of 60% in the permanent teeth.

How Fluorides Work:

Fluorides interfere in the formation and metabolism of the bacteria of Plaque. They have also been seen to have a direct limiting effect on the life of the microorganisms of Dental Caries. Children who are born in areas where the drinking water contains higher levels of fluoride have a higher fluoride content in their enamel, as well as fewer dental caries. The same is true for Children whose water supply is low in fluoride but who take regular dietary fluoride supplements.

Fluoride can be incorporated into the developing enamel in at least two ways; Fluoride ions ( F-) can replace the hydroxyl (OH-) ions during the opposition and calcification stage of crown formation.

Hydroxyapatite is the Major mineral in enamel; if Fluorapatite is formed instead, a more resistant enamel is created. But later findings have found out that the formation of another compound, fluoridated hydroxyapatite, and improved crystalline stability are the important physiochemical mechanisms by which caries resistance is imparted to enamelduring Crown formation.

The surface of the newly completed crown may receive more fluoride before the eruption. This fluoride may be available from the tissue fluid in the dental follicle. After teeth emerge, additional fluoride can be added to the surface enamel by topical application, thereby imparting additional caries resistance to the teeth.

Fluoride might be more effective in reducing caries by reducing the number of caries-producing bacteria as a bactericidal or bacteriostatic agent than by inhibiting the metabolism of these bacteria.

Fluoride Efficacy:

A.Pre-eruptive Fluorides:

i. Fluoridated Community Water: Fluoridation studies began in the United States and Canada during 1945-1946 demonstrated that, after 13-15 years, a level of 1.0 ppm in the drinking water would reduce the prevalence of dental caries in the permanent teeth between 50-60%. The cost of Fluoridation is low. Studies show that fluoridation’s dental health benefits extend through Adulthood.

ii. Fluoridated School Water: In some rural areas, children’s water supply at home is from wells and is deficient in fluorides. This is so true of Developing Countries like India & the countries in the SubContinent. Thus the water supply at school should be fluoridated at 4.5 times the optimal level, yielding results similar to community fluoridation.

iii. Dietary Supplements: The daily ingestion of a fluoride tablet or of fluoride drops is an alternative when children are unable to receive optimal amounts of systemic fluoride through drinking water. Dietary fluoride supplements should be obtained only on prescription. The dentist must prescribe a proper dosage based on the child’s age and the Fluoride content of the child’s drinking water.

B.Posteruptive Fluorides:

 Over the past many years, numerous fluorides agents have been used in a variety of ways to impart greater caries resistance to the enamel surface of teeth after emergence. But the three most popular approaches have been the following:                                                                                 

1. The professional topical application of a fluoride solution or gel

2. The incorporation of Fluoride in toothpaste and      

 3. The development of self-applied gels or rinses

Recently a chewable fluoride tablet has generated curiosity. The tablet, chewed and swished around in the saliva, imparts a topical treatment to the enamel of erupted teeth. When swallowed, it provides a systemic effect on unerupted teeth.

Professional Topical Applications:

Three agents have been tested over the years;

 a) 2 % sodium fluoride ( NaF) solution

b) 8-10% stannous fluoride ( SnF2 ) and

c)1.23% acidulated phosphate fluoride ( APF ) solution or gel.

Stannous fluoride must be freshly mixed. Also, Stannous fluoride has a very disagreeable metallic taste. Stannous Fluoride has a tendency to impart a black or brown stain to areas in which the enamel has recently been demineralised, such as early caries activity.

 APF comes packaged in a ready to use form and in quantities that should be used up before the shelf-life has expired. APF, while slightly acidic to the tastebuds, can be masked and comes in a variety of popular flavours. APF does not stain. APF solutions and gels can be applied with a cotton applicator.

Stannous fluoride and APF preparations are not intended to be swallowed. Patients, therefore, should be encouraged to rinse and spit out following fluoride therapy. 

Application Method:   The technique for either agent, Stannous Fluoride and APF are similar. Basically, the teeth must be clean ( i.e., free of plaque ) and dry. A wet enamel surface will inhibit the desired concentration of Fluoride reaching the enamel.

The Stannous fluoride technique is the application of a freshly mixed 10% SnF2 solution to each tooth surface for 30 seconds with a cotton applicator. The dryness of the teeth is maintained by cotton rolls and a saliva ejector. Each surface must be initially wetted and rewetted for 30 seconds. A popular approach is to apply the solution to one-half of the mouth. The 30-second interval begins after each surface in the area treated has been initially wetted.

The current popular APF technique is the application of a gel contained in a tray. APF solutions and gels can be applied with cotton applicators in the same manner as SnF2 solutions. After one or four minutes the trays are removed and the patient is allowed to spit into the sink and to rinse with water. The difference in fluoride uptake by the enamel surface between 1 and 4 minutes is minimal. The major fluoride uptake by the enamel surface takes place within 30 seconds. The patient’s mouth should be rinsed with water after the procedure.

  Fluoride Dentifrices:

  Three kinds of Fluoride dentifrices have been shown to be effective to warrant the ADA’s Council of Dental Therapeutics Seal of Acceptance, which states that the product “ has been shown to be an effective decay-preventive dentifrice”. These are as follows:

  1.Toothpaste which contains stannous fluoride 0.4% 

 2. Toothpaste which contains sodium mono fluorophosphate fluoride 0.76% 

3. Toothpaste containing 0.2% sodium fluoride.

More recently, new sodium fluoride preparations have shown impressive results. It has reported a 40% reduction in DMFT and DMFS rate at the end of 3 years of children 6-13 years of age when a dentifrice containing 0.243% NaF in a silica abrasive was used.

 Approved Fluoride toothpaste should be recommended for daily use at home. Their effectiveness is limited by the lack of frequent usage. Thus brushing twice a day with fluoride dentifrices gives the best resultsFluoride dentifrices are safe.

Mouthrinses:

The daily or weekly use of mouth rinses or gels is to find methods of providing fluoride to the teeth of children who do not have access to fluoridated water, or professional care or both. In most of the cases, these agents were applied in a school-based classroom project.

Most mouth rinse studies have used a neutral sodium fluoride ( NaF ) solution in a concentration ranging from 0.05% used daily to 0.2-0.5% used every week or two. Effectiveness reported has ranged from 23-50% reduction of DMFS in school-age children.

Mouthrinse and gel-tray programs appear to be effective in fluoridated communities. Three over the counter fluoride preparations– Fluorigard, a 0.05% NaF rinse, ACT, a 0.05% NaF rinse and Stan-Care, a 0.01% SnF2 rinse are accepted by the ADA Council on Dental Therapeutics.

PREVENTION IS BETTER THAN CURE. USE FLUORIDES IN ORAL HYGIENE.

The Role of Stannous Fluoride vs Sodium Fluoride + Triclosan in Toothpastes in Maintaining Oral Health.

Research has shown that good oral health can have a positive impact on overall health. It is no secret that maintaining good oral health is accomplished through an at-home oral hygiene routine that includes the use of fluoride toothpaste. Pharmacists/Dentists play an important role in proper oral care by regularly recommending products to their patients and customers.

One differentiating factor among oral care products such as toothpaste is the active ingredient, fluoride. The most com­monly used fluoride sources today are sodium fluoride, sodium monofluoro­phosphate, and stannous fluoride. The first 2 forms are effective sources of fluo­ride ions that remineralize and strengthen weakened enamel to fight cavities. With added ingredients such as potassium nitrate or triclosan, products containing these types of fluorides can also fight sensitivity or gingivitis, respectively.

A. By comparison, stannous fluoride not only delivers cavity-fighting fluoride, but it also has antibacterial properties that fight plaque and gingivitis, and it provides an anti-sensitivity mechanism of action. Stannous fluoride has both bactericidal and bacteriostatic properties, which fight plaque and treat/prevent gingivitis. The stannous fluoride also deposits a protec­tive mineral barrier over exposed dentinal tubules to help prevent sensitivity pain from triggers such as hot or cold liquids and foods. 

 The anti-plaque, anti-gingivitis, anti-sensitivity, and anti-cavity efficacy of stannous fluoride has been demonstrated in research. Stannous fluoride is the only fluoride source that provides protection against all 3 oral health conditions of plaque/gingivitistooth sensitivity, and cavities.

1.Treating and Preventing Gingivitis;

Gingivitis, the mildest form of periodontal disease, affects more than 50% of the US adult population. The condition is marked by mild inflammation of the gums due to plaque buildup. While brushing the teeth or flossing, the gums may bleed.

Stannous fluoride must be properly for­mulated and stabilized to deliver plaque and gingivitis benefits. A dentifrice con­taining a stabilized 0.454% stannous fluo­ride (SnF2) has been clinically proven to help protect against plaque and gingivitis. Its ability to reduce gingival inflammation and bleeding are supported by an exten­sive body of clinical research. In a ran­domized, double-blind controlled clinical trial examining the prophylactic benefits of stabilized stannous fluoride, Mankodi et al reported a statistically significant and clinically relevant effect on the control and prevention of gingivitis with a stabi­lized 0.454% SnF2 dentifrice compared with a negative control dentifrice over a 6-month period. Compared with the control, brush­ing twice daily with SnF2 was associated with 21.7% less gingivitis (= .001) and 57.1% less bleeding (P <.001).

A second randomized double-blind controlled clinical trial added to the body of evidence supporting the antiplaque and antigingivitis benefits of stannous fluoride. Mallatt et al found that twice-daily use of the SnF2 dentifrice (Crest Pro-Health) demonstrated a 16.9% reduc­tion (<.001) in gingivitis and a 40.8% reduction (P <.001) in gingival bleeding relative to a negative control dentifrice.

 2. Reducing Tooth Sensitivity;

Tooth sensitivity is a common oral health complaint. Approximately one-third of the adult population in North America has experienced dentinal hypersensitivity, and it is thought to be even more prev­alent among periodontal patients, with estimates ranging from 72% to 98%. Sensitivity results from exposed dentinal tubules, most often due to gingival reces­sion and loss of cementum (a thin layer of tissue covering the tooth root) through erosion, abrasion, or other factors.

Stannous fluoride works by occluding dentinal tubulesinhibiting fluid move­ment in the tubules, and thus decreasing nerve stimulation. Clinical research sup­ports the benefits of stabilized stannous fluoride dentifrice in controlling dentinal hypersensitivity. An 8-week randomized study by Schiff et al showed a clinically and statistically significant decrease in hypersensitivity with twice-daily use of a stabilized 0.454% SnF2 dentifrice (Crest Pro-Health) compared with a negative control dentifrice containing 0.243% sodi­um fluoride using tactile (Yeaple probe) and thermal (Schiff Air Index) stimuli for tooth sensitivity assessments.

3. Anti-Cavity Efficacy;

More than 90% of dentate adults in the United States have had dental cavities, making it one of the most common oral health concerns. Dental cavities occur when acids produced by bacteria deminer­alize tooth structure below the surface. Fluoride is commonly used to protect against cavities by inhibiting deminer­alization and enhancing remineralization of partially demineralized enamel. When fluoride is incorporated into the tooth structure, it results in a stronger mineral that is less soluble in bacterial acids than the original.

Stannous fluoride has been shown to effectively support the tooth structure and prevent cavities. In a randomized 24-month study of 955 children aged 9 to 12 years, Stookey et al found statistically significantly fewer cavities in participants receiving an experimental 0.454% stabi­lized SnF2 dentifrice (1100 ppm F) com­pared with those who received a sodium fluoride positive control dentifrice (1100 ppm F). Among participants who attended at least 60% of supervised visits, reduc­tions in the incidence of cavities over the 2-year period ranged from 17% (= .019) to 25.5% (= .002).

B. Why a Chemical Banned From Soap Is Still in Your Toothpaste? Well, I am here talking about Triclosan which is used as an active ingredient in Colgate Total in the United States.

Nearly a year has passed since the US Food and Drug Administration banned Triclosan from hand soaps and body wash in the country. But the antimicrobial and its chemical relatives are still on the ingredients list for loads of other products people in the US and internationally put on their skin and in their mouths—more than 2,000 of them, according to a statement published Tuesday (June 20,2017) and signed by 200 doctors and scientists from all over the world.

Citing well over 100 peer-reviewed papers, they concluded that triclosan does more harmthan good, and should not be in products for everyday use.

The additive was shown to be an endocrine disruptor in several animalstudies—meaning it could alter hormone systems, leading to reproductive and developmental problems. In one study, male rats given triclosan had reduced testosterone and sperm production, for example. In another, female rats exposed to the chemical had miscarriages. Research has also shown that due to the indiscriminate bacteria-killing feature of triclosan and its related compounds, they have the potential to contribute to antibiotic resistance and could alter the gut microbiome.

Human studies are lacking, but the scientists who issued the statement say the animal research is enough to prompt investigation into possible human effects and to call for a cautious approach to its use in the meantime. And the fact that it shows up in human urine and blood plasma at high rates ought to make the red flags from animal studies especially pressing, they argue. One study, in China, found triclosan in the urine of 99% of people tested. Another, in the US, found it in 75% of urine samples. Studies have determined triclosan can cross the placenta, and it showed up in cord blood samples and amniotic fluid of pregnant women tested in the US and India. It shows up in women’s breast milk, too.

“We’re not saying they should be banned, but they shouldn’t be used without good reason. But to the best of our knowledge, there is no health benefit,” says chemist Arlene Blum, who founded the Green Policy Institute, an advocacy group that spearheaded the statement on triclosan.

“Quite frankly, it creates more problems than it really solves,” says Larry Robertson, director of the human toxicology program at the University of Iowa, says. He is among the scientists who signed the document at a conference of toxicologists in Florence, Italy, last year.

Take Colgate Total toothpaste, for example. The label boasts triclosan as an active ingredient. But, Robertson says, “You don’t want your teeth disinfected. The whole idea of brushing your teeth is to remove film and residue—we don’t need to disinfect our mouths. There is a spectrum of beneficial organisms that living in your mouth. You don’t want to get rid of them.

More than a decade ago, the US Centers for Disease Control wrote that hospital personnel shouldn’t be fooled by products that tout their triclosan content, despite its enticing labelling as an antimicrobial. “No evidence is available to suggest that use of these products will make consumers and patients healthier or prevent disease,” the CDC wrote in a 2003 report“No data support the use of these items as part of a sound infection-control strategy.” In Europetriclosan has been banned in ingestible for years, and in 2015, the EU Standing Committee on Biocidal Products rejected an application for the approval of the use of the chemical in hygiene products. Consumer goods that use triclosan have to be phased out in the EU this year (paywall).

Americans shouldn’t wait for the FDA to tell them to stop using triclosan“The FDA was trying to regulate triclosan since the 70s—and it took them 42 years to do hand soap,” Blum says.

Instead, she hopes public awareness will spur manufacturers to drop the ingredient voluntarily. Already, after showing Target executives an informational video about triclosan, the retailer agreed to remove it from its store-brand line of body products.

CHALLENGES OF ORAL CANCER IN INDIA:

Chronic diseases such as cancer, and other non-communicable diseases are fast replacing communicable diseases in India and other developing countries. Tobacco is the most important identified cause of Oral cancer followed by dietary practices, inadequate physical activity, alcohol consumption, infections due to viruses and sexual behaviour.

              Cancer prevention includes primary and secondary prevention measures. Public education on ‘tobacco and its health hazards’, recommended dietary guidelines, safe sexual practices, and lifestyle modifications form the main features of the primary prevention of cancer.

           Incorporating screening for oral cancers into peripheral health infrastructure can have a significant effect on reducing mortality and form the mainstay for the secondary prevention measure.

1.High Burden of Oral Cancer in India:

Oral cancer is the most common cancer in India amongst men (11.28% of all cancers), fifth most frequently occurring cancer amongst women (4.3% of all cancers) and the third most frequently occurring cancer in India amongst both men and women.

                  Oral cancer is a major problem in the Indian subcontinent where it ranks among the top three types of cancer. Age-adjusted rates of oral cancer in India is high, that is, 20 per 100,000 population and accounts for over 30% of all cancers in the country. The variation in incidence and pattern of the disease can be attributed to the combined effect of ageing of the population, as well as regional differences in the prevalence of disease-specific risk factors.

Oral cancer is of significant public health importance to India. Firstly, it is diagnosed at later stages which result in low treatment outcomes and considerable costs to the patients who typically cannot afford this type of treatment.

                   Secondly, rural areas in middle- and low-income countries also have inadequate access to trained providers and limited health services. As a result, the delay has also been largely associated with advanced stages of oral cancer. Earlier detection of oral cancer offers the best chance for long-term survival and has the potential to improve treatment outcomes and make healthcare affordable.

                 Thirdly, oral cancer affects those from the lower socioeconomic groups, that is, people from the lower socioeconomic strata of society due to higher exposure to risk factors such as the use of tobacco.

                  Lastly, even though clinical diagnosis occurs via examination of the oral cavity and tongue which is accessible by current diagnostic tools, the majority of cases present to a healthcare facility at later stages of cancer subtypes, thereby reducing chances of survival due to delays in diagnosis.

                Oral cancer will remain a major health problem and efforts towards early detection, and prevention will reduce this burden.

2. Definition of Oral Cancer:

 Oral cancer is defined as the cancer of the lip, mouth, and tongue, to include the anatomic description of the oral cavity. This case definition is adopted and conforms to the definitions of oral cavity cancer by the International Classification of Diseases (ICD) Coding scheme, WHO case definitions and IARC. Based on these criteria, oral cavity cancer is the 8th most frequent cancer in the world among males and 14th among females, the main risk factors being tobacco and alcohol use.

3. Measurement of Disease Incidence:

Incidence is defined by the number of new cases of oral cancer, which occur in a defined population of disease-free individuals, over a specified period of time. The incidence rate of oral cancer is generally expressed for 100,000 population-over one year (or a range of years).

               Age- and sex-specific incidence rates are calculated to provide an estimate of the risk of oral cancer in defined groups in India. Additionally, the incidence of oral cancer is age specific.

                Cancer incidence was higher in females compared to males. The incidence in rural areas was quite low compared to urban counterparts. It is estimated that presently nearly one million new cancer cases are being detected annually in the country.

       In India, cancer mortality rates are under-reported due to the poor recording of the cause of death.

4. Incidence and Trends of Oral Cancer in India:

Oral cancer is a heterogeneous group of cancers arising from different parts of the oral cavity, with different predisposing factors, prevalence, and treatment outcomes. It is the sixth most common cancer reported globally with an annual incidence of over 300,000 cases, of which 62% arise in developing countries.

         There is a significant difference in the incidence of oral cancer in different regions of the world, with the age-adjusted rates varying from over 20 per 100,000 population in India, to 10 per 100,000 in the U.S.A, and less than 2 per 100,000 in the Middle East.

5. Aetiological Factors:

High incidence of oral cancer in India can be attributed to a number of aetiological factors. Studies reported the use of tobacco(smoking or chewing) or alcohol intake associated with oral cancer. Khandekrar et al. reported tobacco consumption habits among subjects that included chewing (in the form of betel quid, or khaini) and smoking (bidis and cigarettes) as the common cause of oral cancer. Based on the TNM classification, 48% of these oral cancer cases presented in later stages, that is III and IV. Mehta et al.

                  According to WHO estimates, the annual cigarette consumption per adult in developing countries is on the rise. The WHO has estimated that 91% of oral cancer in this part is directly attributable to tobacco usage.

                 Even for coronary artery disease, cigarette smokers have 70% greater mortality than non-smokers do.

               One study discussed the association between alcohol use and oral cancer. Cancela et al. [9] reported a significant association between risk between alcohol intake and development of oral cancer.

a.Tobacco Use:

Tobacco consumption remains the most important avoidable cancer risk. India is the third largest producer and consumer of tobacco. The country has a long history of tobacco use in a variety of ways of chewing and smoking. The principal impact of tobacco smoking is seen in the higher incidence of cancers of the lung, larynx, oesophagus, pancreas and bladder. Bidi smoking is associated with cancer of oro-pharynx as well as larynx.

Around 80% of oral cancers are directly attributable to tobacco use. Tobacco-related cancers account for nearly 50% of all cancers among men and 25% of all cancers among women. The burden of tobacco-related cancers in India by 2001 has been estimated to be nearly 0.33 million cases annually. There are predictions of incidence of 7-fold increase in tobacco-related cancer morbidity between 1995 and 2025. Further, there will be an overall increase of 220% of cancer deaths simply related to tobacco use by the year 2025.

                       Besides smoking, use of smokeless tobacco is also widely prevalent. The use of Betel quid, which consist of pieces of areca nut, processed or unprocessed tobacco, aqueous calcium hydroxide (slaked lime), and some spices wrapped in the leaf of piper betel vine leaf. This is very common and is accepted socially and culturally in many parts of India.

                     Additionally, gutka, zarda, kharra, mawa, and khainni are all dry mixtures of lime, areca nut flakes, and powdered tobacco. In recent years, commercially available sachets of premixed areca nut, lime, condiments with or without powdered tobacco have become very popular, particularly among younger Indians. Typically, the pan or gutka is kept in the cheek and chewed or sucked for 10–15 minutes, with some users keeping it in overnight.

b. Alcohol:

Epidemiological studies carried out in India and abroad have shown that increased alcohol consumption is causally associated with cancers at various sites, mainly oral cavity, pharynx, larynx, and oesophagus. Heavy alcohol drinkers are frequently heavy smokers as well. A synergistic effect with cigarette smoking has been suggested. Also, excessive alcohol consumption is responsible for the incidence of primary liver cancer.

c.Infections:

Studies carried out in India have also confirmed the role of HPV and cervical cancer. Besides cervical cancer, the evidence is also indicative of the role of HPV with Oral cancer and other malignancies. Other virus–cancer relationships are HIV and Kaposi’s sarcoma and some forms of lymphoma.

6. Projections:

Cancer is not uncommon in India, where the number of people living with the disease is estimated to be around 2.5 million, with over 0.8 million new cases and 0.55 million deaths occurring each year. According to the International Agency for Research on Cancer (IARC), cancers of the oral cavity, lungs, oesophagus, stomach, cervix, and breast are some of the most commonly occurring forms in both the male and female population of India.

Oral cancer, in particular, will continue to be a major problem. Projections by Globocan demonstrate that oral cancer crude incidence will increase in India by 2020 and 2030 in both sexes. Variability in the age-adjusted incidence rates of oral cancer in different regions of India has increased over the years.

       It is imperative that cost-effective oral cancer screening and awareness initiatives be introduced in high-risk populations such as those found in India.

A study in India demonstrated that oral cancer screening by trained health workers can lower mortality of the disease—especially in individuals with a history of tobacco use.

7.Cancer control and prevention in India:

Cancer is one of the most important causes of morbidity. Its burden on the economy for providing health care is substantial. In addition to this, the indirect costs such as loss due to premature deaths, loss due to the hindrance of productivity, economic dependence, etc. cannot be quantified. Hence cancer prevention and control is the most appropriate measure.

The primary prevention focused on health education regarding hazards of tobacco consumption, genital hygiene, and sexual and reproductive health. Secondary prevention aims at early diagnosis of cancers of oro-pharyngeal cancers by screening methods.

8. Cancer prevention strategies:

a.Primary prevention:

One-third of the cancers occurring in the Indian population is related to tobacco use and thus are preventable.

The main strategy for the control of tobacco-related cancers would be through primary prevention. Extensive persuasive health education needs to be directed to control/reduce the tobacco habit. Teen-aged students need to be targeted as most of them pick up habits at this time. The school curricula should involve messages for a healthy lifestyle and warn about the harmful effects of tobacco and alcohol.

            Top priority should be given to control of tobacco; that is likely to have the greatest impact on reducing cancer incidence and cancer mortality. Based on the above facts the strategies which should be implemented in India, are (i) education of public,(ii) practice of tobacco control and (iii) advocacy for tobacco control.

             The tobacco control could be achieved by the government (including through legislation) and societal actions. Public education on tobacco and its health hazards, price increase and legislative measures form the main features of primary prevention of tobacco-related cancers. Heavy consumers of alcohol should be advised to moderate their consumption and to stop smoking.

               Nutrition education is important for increasing public awareness, promoting good health and for control of cancers. Dietary intervention for cancer prevention in terms of lowering dietary fat content, increasing intake of fibre, fruits and vegetables is needed to control cancer and other diseases, besides avoiding risk factors such as smoking and alcoholism and exposure to genotoxicants.

b. Secondary prevention:

Oral cancer screening.

.Oral cancer satisfies the criteria for screening and oral visual inspection is a suitable test for oral cancer screening.

Mouth self-examination could further reduce the cost of the screening and increase awareness in high-risk communities in India. Such a simple and cost-effective strategy has the potential to have a significant impact on the awareness of oral cancer in the broader community.

9. Future Challenges:

Despite the fact that oral cancer and consequences can be prevented, treated, and controlled, there exists a significant gap in the Indian public’s knowledge, attitudes, and behaviours.

                    Efforts must be made to introduce a suite of preventive measures that have the potential to significantly reduce the burden and to help bridge the gap between research, development and public awareness. Knowledge dissemination to help people adopt behaviour patterns to improve their health and decisions making process and to provide required public health education and training to promote lifestyle modifications are key to confronting the challenge.

                 The greatest threat of the oral cancer burden exists among the lower socioeconomic strata. This segment of the population is the most vulnerable because of higher exposure to the risk factor—tobacco—which complicates the situation further. They have the most limited access to education, prevention and treatment.

                These disparities should be addressed to push for provision of easy, accessible, detection, and treatment services. Prevention through action against risk factors, especially tobacco will be key to reducing the burden amongst these groups.

The Effect of Poor Dental Hygiene on your Overall Health.

Oral Health is essential to general health and well-being at every stage of life. A healthy mouth enables not only the nutrition of the physical body but also enhances social interaction and promotes self-esteem and feelings of well-being. The mouth serves as a “window” to the rest of the body, providing signals of general health disorders. For example, mouth lesions may be the first signs of HIV infectionaphthous ulcers are occasionally a manifestation of Coeliac disease or Crohn’s diseasepale and bleeding gums can be a marker for blood disordersbone loss in the lower jaw can be an early indicator of skeletal osteoporosis, and changes in tooth appearance can indicate bulimia or anorexia. The presence of many compounds (e.g., alcohol, nicotine, opiates, drugs, hormones, environmental toxins, antibodies) in the body can also be detected in the saliva.

Oral conditions have an impact on overall health and disease. Bacteria from the mouth can cause infection in other parts of the body when the immune system has been compromised by disease or medical treatments (e.g., infective endocarditis). Systemic conditions and their treatment are also known to impact oral health (e.g., reduced saliva flow, the altered balance of oral microorganisms).

Periodontal disease has been associated with a number of systemic conditions. Major chronic diseases – namely cancer and heart disease – share common risk factors with oral disease. Recognition that oral health and general health are interlinked is essential for determining appropriate oral health care programmes and strategies at both individual and community care levels.

That the mouth and body are integral to each other underscores the importance of the integration of oral health into holistic general health policies and of the adoption of a collaborative “Common Risk Factor Approach” for oral health promotion.

The Common Risk Factor Approach:

Traditionally, oral health promotion has focused on the care of the teeth and gums, in isolation from other health programmes.

The Common Risk Factor Approach (CRFA) to health promotion takes a broader perspective and targets risk factors common to many chronic conditions and their underlying social determinants. The key concept of this approach is that concerted action against common health risks and their underlying social determinants will achieve improvements in a range of chronic health conditions more effectively and efficiently than isolated, disease-specific approaches. Adoption of a common risk factor approach is more resource-efficient than a targeted disease-specific approach because:

  • most chronic diseases have multiple risk factors
  • one risk factor can impact on several diseases
  • some risk factors cluster in groups of people
  • risk factors can interact – in some instances synergistically – with each other.

The common risk factor approach provides a rationale for developing multi-sectoral healthy alliances between health professionals, statutory, voluntary and commercial bodies and the general public.

Common Risk Factors for Oral Health;

Oral disease is the most widespread chronic disease, despite being highly preventable. The common risk factors that oral disease shares with other chronic diseases/conditions are:

1.Diet;

– It is a Risk factor for dental caries, coronary heart disease, stroke, diabetes, cancers, obesity.

The Food Pyramid is designed to help people to eat a  balanced diet combining several different types of food in the right amounts. The “top shelf” of the pyramid represents foods high in fat, sugar and salt which are not essential for health and which should be used sparinglythe “bottom shelf” represents foods high in carbohydrates (e.g., bread, cereals and potatoes) which should comprise the bulk of our diet. 

The top shelf of the Food Pyramid is of particular relevance to oral health as high consumption of foods/drinks containing added sugars is a direct cause of dental caries. The oral health message to restrict consumption of foods/drinks containing added sugars to meal times complements the healthy heart message to reduce consumption of foods high in oils and fats.

2.Tobacco smoking/chewing;

– It is a Risk factor for oral and other cancers, periodontal disease, coronary heart disease, stroke, respiratory diseases, diabetes

Your Mouth – The Effects of Smoking:

Tobacco contains chemicals that are harmful to the human body and the smoking or chewing of tobacco is the cause of 80–90% of oral cancers. Other oral consequences of tobacco consumption include increased the risk of periodontal diseasebad breath, tooth discolouration, an increased build-up of dental plaque, and delayed healing following tooth extraction, periodontal treatment or oral surgery.

Smoking is bad for the health: it increases the risk of several types of cancers (lung cancer, pancreatic cancer, cervical cancer, cancer of the kidney, liver cancer, cancers of the mouth, lip, throat, bladder cancer, stomach cancer and leukaemia), emphysema and other respiratory diseases, coronary heart disease, stroke, diabetes and ulcersSmoking is also associated with adverse pregnancy outcomes.

Smoking is the single most important preventable cause of illness and death. It is responsible for an estimated 30% of all cancer diseases and deaths and 90% of all lung cancers. Compared to those who have never smoked, smokers are almost twice as likely to have a heart attack. Smokers shorten their life expectancy by 10–15 years on average. 

3.Alcohol consumption;

– It is a Risk factor for oral and other cancers, cardiovascular disease, liver cirrhosis, trauma.

Alcohol is a risk factor for oral and other cancers, cardiovascular disease, liver cirrhosis and trauma. The risk of oral cancer is six times higher in those who drink alcohol compared to nondrinkersAlcohol is the primary cause of liver cancer and is also a risk factor for breast cancer and colorectal cancer.

Alcohol is absorbed from the stomach into the bloodstream and affects the central nervous systemAlcohol is a depressant.

4.Oral Hygiene;

– It is a Risk factor for periodontal disease and other bacterial and inflammatory conditions

 Oral hygiene refers to individual habits and professional methods used to control the bacterial biofilm (dental plaque) that grows on tooth surfaces. If not removed regularly, dental plaque can lead to tooth decay and periodontal disease. Toothbrushing as a daily routine is the most important method of plaque control.

Early assimilation of good oral hygiene into general hygiene practices promotes better overall oral health and general health. Oral hygiene practices should be included in guidelines for personal hygiene taught in schools 

Epidemiological studies confirm an association between poor oral hygiene (periodontal disease )  and higher risk levels of cardiovascular disease and low-grade inflammation.

5. Injuries;

– It is a Risk factor for trauma, including dental trauma.

Injuries are a risk factor for trauma, including dental trauma. Most traumatic injuries to teeth arise from accidents during normal, everyday activities such as informal play or sports. The wearing of mouthguards or helmets with face shields during organised contact sports will reduce the likelihood of traumatic injuries to the head, face and teeth. 

6.Control & Stress;

– It is a Risk factor for periodontal disease and cardiovascular disease

Stress and control are risk factors for periodontal disease and cardiovascular diseases. Stress is the body’s reaction to external forces or events that cause physical, emotional or mental tension. When an individual feels stressed, adrenaline and stress hormones (e.g., cortisol) are released to prepare the body for the “fight-or-flight” response.

Excessive stress can lead to health problems and lifestyle behavioural changes (e.g., taking up or increasing smoking, increasing alcohol intake, changing dietary habits, becoming physically inactive, neglecting oral and personal hygiene) which further increase health risks.

Chronic stress (e.g., low social support, low socioeconomic status, work stress, marital stress, caregiver strain) is a known risk factor for cardiovascular disease and periodontal disease.

7. Socioeconomic status

– It is an Independent risk factor as well as the underlying determinant of other risk factors.

The link between general health and socioeconomic status is well established. There is also a body of evidence showing that poor oral health is associated with low socioeconomic status or deprivation.

In addition to being a risk factor in itself, socioeconomic status is also an important underlying determinant of other common risk factors. It has been seen that:

i)those in the lower social class groups were more likely to smoke, ii)excessive alcohol consumption was more common among lower social class groups.

In the end, I would end by quoting Dr David Satcher MD, PhD, a former US Surgeon General as ” YOU ARE NOT HEALTHY WITHOUT GOOD ORAL HEALTH”.

Higher Education in India: Are the students failing or the system?

Higher Education in India is provided by the public sector as well as the private sector. It is accomplished by way of 2 Central Boards ( CBSE & CISCE ) and the respective State Boards.

Education and the way of teaching methods, unfortunately, have not seen a change despite huge advances in science and technology. The choice of teaching methods depends on what’s fits the Teacher his/ her educational philosophy, classroom demographics, subject areas and school mission statement.

Unfortunately, most of the Teachers come from middle class and low-income backgrounds and have low self-esteem in them. This is because of the society that perceives Teaching as a low-grade job. Also, Teachers are lowly paid as compared to their colleagues in other sectors. No wonders that Teachers take out their frustration on the hapless children. Thus most of them early on have a mindset of thrashing the child rather than teaching the child.

Teaching should be FUN but when it becomes punishing it pushes the student away from Education and Studies. The other factor is that Educators do not think of innovative methods to keep the children engrossed. One of the greatest challenges in teaching students is to develop their creativity and help them see things from a different perspective. Breaking the boundaries of classical thinking is also called Thinking outside the box.

Children are mischevious and Naughty. It is the skill and expertise of the Teacher to control the children without having to raise their hands. It has been seen that the most loved Teacher in any School is one who hears out the children and does not spank them. In fact, the children eagerly await for their Class session. The positive bonding between the Teacher and his Students encourages the latter to think outside the Box and make the Subject easy to comprehend for them. Beating is not the solution. Children need to be handled with Kid Gloves by the Teachers.

The old adage “spare the rod and spoil the child” is no longer valid. It should rather be “spare the rod and save the child”. Corporal punishment can leave a permanent scar on the body and mind of a child and acts as an impediment to his/her development. Such behaviour on part of teachers is known as “displacement of anger”. The hapless children become soft targets for the teachers to express their anger says a noted psychiatrist.

Education hasn’t changed much since I completed my Schooling at Bishop Cotton School in 1988. There is the still the Bookish method to grasp knowledge rather than the Practical way of learning it. Unfortunately, our Schools in India with Inferior quality Educators are less inclined to look for out of the book solutions. This mindset of rote learning among the students has given India a workforce with low IQ and missing civic sense. Teaching should be considered the noblest of professions because here you are going to make the Future Gems of your Country.

We cannot have an Education that is primarily based on One Size Fits All. It is rubbish. We are ruining our Children Future and playing havoc with their innocent minds. No wonder that we have the highest number of suicides in our Education system with a majority of our children unable to cope with extremities and cave in too low grades and examination failures.

It’s not necessarily for all to be Scholars. Some students will excel in Sports, some others in Music, some others in Artistic Drawings, some in Dance, some in Singing, Some going onto becoming Actors and so on. There is a huge untapped potential of the Children activities waiting to be groomed.
Sports should be made a Compulsory Subject. India can get its Future Olympians if it takes care of them from the very beginning. Policymakers and Educationists should put less emphasis on Education and more towards Extracurricular activities such as Sports.


Education should be modelled around each Child as every child is different from the other and unique in his/ her way. Thus education should be tailored to meet his/ her Objective rather than the One Fits All Model currently in place. There should be Counsellors in schools who can help guide the child and see his/her expertise among different subjects and give recommendations to the Teachers so that his/her Syllabus can be tailor-fit for his core strengths.


Also, Emphasis should be on inculcating Civil manners & Obedience in our students from an earlier stage. Respect to Individuals without discrimination of caste creed and colour should be ingrained in the children. A Nation does not become great because of its Economic power or by the strength of its Armed Forces but by an Inclusiveness of people working for the betterment of their Nation in harmony and sync with one another. And all this begins at the School Level. Here the children at an early ripe age can be moulded for achieving it. Extracurricular activities should be made compulsory. You will get your future gems from here.

I have gone through the Education system of Countries and Finland comes Ist followed by Japan in the 2nd Position and South Korea in the 3rd position among the World rankings in Education. It is not rocket science to have an Education Model moulded along the Finland study of Education in India. The Government ought to think and take action along these lines because here the Future of our Students is concerned. Why cannot the children have an Education that is FUN to learn, inculcates civic sense & responsibility rather than the current method of Rote learning.

It is incumbent upon our Educators and Policy Makers that what would they like of our Children. Would they not like our Children to be Happy and Stress-free of Education? Would they not want our children to have high moral values and excel in sports. It is up to the Education Policy Makers to take a Stand. India needs a complete overhaul of its Higher Education System.

What do you mean by Dental Health? Why is Dental Health important for General Health & Well Being?

1. What do we mean by dental health?

Dental health refers to all aspects of the health and functioning of our mouth especially the teeth and gums. Apart from working properly to enable us to eat, speak, laugh (look nice), teeth and gums should be free from infection, which can cause dental caries, inflammation of gums, tooth loss and bad breath.

a. Dental caries, also known as tooth decay or cavities, is the most common disorder affecting the teeth. Dental caries affects to 60 to 65 % of the population in India. The main factors controlling the risk of dental caries are oral hygiene, exposure to fluoride and a moderate frequency of consumption of cariogenic foods.

b. Teeth are also affected by tooth wear or erosion. This condition is a normal part of ageing where tooth enamel is lost due to exposure from acids other than those produced by plaque.

c. Attrition and Abrasion are other forms of tooth wear. Attrition occurs when teeth are eroded by tooth-to-tooth contact such as teeth grinding. Abrasion is caused by external mechanical factors such as incorrect tooth brushing.

d.Periodontal disease, also known as gum disease, is caused by infection and inflammation of the gingiva (gum), the periodontal connective tissues and the alveolar bone. If left untreated it leads to Tooth loss. Periodontal diseases affect an estimated 50 to 90 % of the general population. Periodontitis is responsible for more than 40% of all teeth lost after the age of 35 and is probably the leading cause for Edentulous mouths.

2. Why is dental health important for general health and well-being?

The health of our teeth and mouth are linked to overall health and well-being in a number of ways. The ability to chew and swallow our food is essential for obtaining the nutrients we need for good health. Apart from the impact on nutritional status, poor dental health can also adversely affect speech and self-esteem. Dental diseases impose both financial and social burdens as treatment is costly and both children and adults may miss time from school or work because of dental pain. 

 Neglecting Oral Health is as serious neglecting General Health. Oral Cancer ranks in the top three of all cancers in IndiaOral Cancer is a significant public health problem, related directly to Oral Health. 95% of Oral Cancer cases are attributed to Smoking and use of Chewable Tobacco products. Besides smoking, use of smokeless tobacco, Betel nut, gutka, Zarda and khaini are also high-risk factors for cancers of the oral cavity.

Oral Diseases are also major public health problems. The four most Common NCD’s – Cardiovascular Diseases, Diabetes, Cancer and Chronic Obstructive Pulmonary Diseases, share a common risk factor for Oral Diseases.