A treatment technique for tooth decay in deprived communities

World Health • 47th Year, No.1 , January-February 1994 IS A treatment technique for tooth decay in deprived communities Jo Frencken & Fiona Makoni No more equipment thon this is necessary for applying sealants and carrying out fillings. A technique tried out with success in Zimbabwe called Atraumatic Restorative Treatment suggests an effective way of bringing good quality oral health care to rural and outer-urban communities elsewhere in Africa. During the seventh international conference on dental research, held in Harare in December 1992, DrS. Thorpe ofthe WHO Oral Health Programme in Brazzaville stated that more than 90% of tooth decay in Africa goes untreated. If we look at the oral health situation prevailing amongst 15-year-olds in Zimbabwe, we see that they have on average 1.5 decayed teeth. Of all those decayed teeth only 7% have been treated. The untreated teeth are just left to decay further until they hurt and have to be removed. This shows the great discrepancy which exists between the presence of disease (tooth decay) and its possible treatment (fillings). What are the reasons for the lack of care in this and other African societies? A mixture of the following factors are considered to be responsible: inappropriate dental curricula for the African setting; inadequate numbers and distribution of oral health personnel; inadequate financial resources allocated by governments; inadequate supply of dental equipment and materials; low awareness of oral diseases by the population; and little or no involvement of communities in promoting oral health and providing oral health care. 16 In Zimbabwe, as in many other African countries, most oral care is provided in dental surgeries, but these are predominantly found in urban areas. In a few places, care is provided through outreach programmes which usually involve extracting badly decayed teeth and offering oral health education, that is, emergency care and health promotion activities. Rarely is any treatment provided at an early stage of disease, nor are any preventive measures taken. Why is it difficult to incorporate an element of cure into community oral health programmes? After all, the provision of curative care for common diseases is one of the elements of the primary health care approach. The answer lies in the training of oral health personnel. Traditionally, oral care and education rely heavily on modem technology, particularly electrically driven equipment. This machinery-based type of care was introduced in the early part of this century in the now industrialized countries to assist dentists in mastering an uncontrolled rate of tooth decay in their communities. But over the last two decades, an enormous amount of oral health- related research and promotional activities has been carried out and has resulted, amongst other achievements, in a decrease of tooth decay in the industrialized world. A new concept So a new thinking has developed involving a shift from the concept of "disease" (ftlling holes in the teeth) towards the concept of "health" (trying to preserve teeth and gums through small interventions and oral health promotion activities). This new thinking is taken for granted amongst O(al health personel in the industrialized world, but it is still based on modem technology. So the question is now raised: Do we really need electrically driven equipment to deal with all tooth decay? In other words, is it possible to develop a technique which takes into consideration the results of research on the processes of oral disease and on improved filling materials, and which at the same time is based on the philosophy of "health" rather than "disease"? Such a technique would allow for an element of cure, besides emergency care and oral health- promoting activities, within primary oral health care programmes for rural and outer-urban communities in Zimbabwe and other developing countries. Experiences in using mobile dental equipment in the African setting have shown that such equipment is not cost-effective at all and, after some time, can be seen lying idle. This reinforces the need for developing a treatment technique that World Health • 47th Year, No. 1, Jonuory-Februory 1994 is both appropriate and of good quality. Such a technique would improve the oral health not only of people living where electricity is not available but also those who live where there is electricity but where nobody can afford to buy and maintain expensive dental equipment. After the technique was introduced to private practitioners in Zimbabwe, some have found it to be a big step forward in treating children since it largely eliminates the concept of fear while still providing good quality care. The technique that has been developed is called Atraumatic Restorative Treatment (ART), and is A comfortable position for both the operator and the young patient, and simple, effective equipment. World Health • 47th Year, No. 1, Jonuory-Februory 1994 based on cleaning the hole in the tooth by removing soft tooth material using a small hand instrument and, after cleaning is completed, filling the cavity with glass-ionomer cement. This filling material sticks to the tooth surfaces and makes the tooth stronger than can be done by any other type of filling material. Cotton pellets are used to clean the cavities in teeth, and cotton rolls to control the saliva and keep the teeth dry during treatment. If the patient complains of pain during cleaning, a local anaesthetic can be administered. A head lamp powered by a small portable battery provides lighting. Encouraging results Researchers from the Netherlands, Thailand, and Zimbabwe are carrying out a three-year field trial on the cost- effectiveness of the ART technique in a village community in Thailand. The evaluation results, which have been presented at scientific meetings, are very encouraging (see article on page 5). After one month, only two children remembered having had pain after treatment, whereas 97% of the children and adults were pleased with the treatment they received. Clinically, 86% of the fillings on the chewing The DMF tooth index This is a count that makes it easy to measure and compare the level of denta l caries in a community. It is the total of Decayed, M issing and Filled teeth . The global goal for the end of th is century is a DM F tooth index of th ree or lower at 12 years of age. In the 1960s, the index averaged less than one for most Th ird World countries, and up to 1 2 for some industria lized countries. Figures reported in 1993 show a sharp reversa l of trends: 2.08 for devel op in g a nd 3. 17 for industria lized countries. surfaces, where the decay was mainly located, were judged successful after two years. In the 13-year-olds and over, the success-rate was higher (91 %) than in the 6- to 12-year-olds (83%). In Zimbabwe, the incorporation of this treatment technique into the primary oral health care concept was considered a big step forward in the government's endeavour to improve and extend oral health care to a much greater part of the population. A demonstration programme was developed which focused initially on 1st year secondary school students. Oral health promotion among children in Madagascar: prevention is always better than cure. This group was chosen mainly because research has shown that oral diseases are prevalent at this age and, furthermore, that they are most open to oral health promotion activities. 17 The oral health services and promotion programme consists of the following elements: 1. examination of the students to identify individuals who need care; 2. oral health promotion activities in class and on an individual basis; 3. provision of preventive oral health measures like sealing the tooth surfaces, using glass-ionomer cement, and removing hard deposits from the tooth surface; 4. provision of treatment for tooth decay, using the ART technique; 5. discussions with the school staff on maintaining good oral health in the schoolchildren after the team has left; 6. evaluation of the programme in general and the care provided over the year. The programme started in March 1993 in six secondary schools in the Greater Harare area. Among 572 children examined, 553 required some form of preventive or curative attention. The programme is carried out by two dentists and two newly qualified dental therapists, and is being incorporated in the teaching of third-year dental therapy students. The latter assist the operators, give oral health education, and carry out the removal of hard deposits on the tooth surfaces. So far, this procedure has been well received by school staff and students, the vast majority of whom were very pleased with the care they received which otherwise they would never have had. Eventually, the programme aims at providing improved oral health care which will be sustainable in terms of quality and durability as well as affordable and acceptable by the people, and which can be brought to them at low cost to the government. • Dr Jo Frencken and Dr Fiona Makoni are working with the Dental Department of the Ministry of Health and Child Welfare, P 0 Box 8559, Causeway, Harare, Zimbabwe.