A family care programme in India

18 World Health • 47th Year, No. 1, January-February 1994 A family care programme in India Amrit T ewari Dental caries (tooth decay) and gum diseases are the two most common oral health problems in human beings. Caries has a worldwide distribution. It is caused by bacteria which are normally present in the mouth sticking to the teeth in a concentrated form with the help of a thin slimy layer called dental plaque. When an individual takes foods with fermentable carbohydrates (fruits, milk sugars as well as sucrose and some starches), these germs start to make acid by action on the carbohydrate in the foods: Plaque bacteria+ fermentable carbohydrate _, Acid Acid + tooth enamel _, Cavity The more often a person takes each day foods or drinks with fermentable carbohydrate, the more opportunities occur for the acid produced to cause cavities in the teeth. Fluoride helps to prevent cavities by strengthening the teeth and weakening the bacterial action. Until1980 dental caries severely affected most of the population in the developed countries where levels as high as twelve teeth were found to be decayed in children aged between 12 and 15. But since 1980, it has been controlled in most Western countries- e.g. , Denmark, Netherlands, Norway, Sweden, United Kingdom and the United States- and also in some others- Australia, Hong Kong, New Zealand, and Singapore - where the distribution of decayed teeth has been brought down to as low as one to two per 12-year-old child. This is mainly due to the appropriate use of fluorides In India, as in many countries, dental caries is on the increase. and oral hygiene measures, especially brushing with fluoridated toothpaste. In developing countries such as Bangladesh, India, Nepal, and Sri Lanka, the incidence of dental caries used to be comparatively low, but now has been found to be on the increase. This is primarily due to the fact that organized preventive measures have not been initiated, priority being given to diseases with high mortality and high morbidity or to curative and restorative services. In the rural areas of most of these countries, the dentist to population ratio may be as low as 1:300 000. Since there is hardly any oral health cover for the rural communities, what can be done to prevent the steady increase in dental caries? The answer springs to mind: "Why don't they brush their teeth with fluoride toothpaste?" Most people living in rural areas of India cannot afford the money to buy a toothbrush and fluoride toothpaste, which for a Soluble tablets of sodium fluoride offer a low-cost means of providing the rural populations in developing countries with a simple mouthwash that can protect their teeth from dental caries. family of four would mean an expenditure of 60 rupees (US$ 2) per month. This difficulty came to the fore when a demonstration module for primary prevention of oral diseases in rural India was being prepared, involving 120 000 people who had no access to any professional oral health care. As application of fluoride to the teeth every day in low concentrations has been so effective in preventing dental caries, a cheap and easy-to-use method was devised as an alternative through rinsing with soluble sodium fluoride tablets. Fluoriwash packets These tablets are known by the name of "fluoriwash"; they contain 10 mg of sodium fluoride (4.4 mg of fluoride) , and are available in packets of 30 tablets. One tablet, when dissolved in five teaspoonfuls (25 ml) of cold, clean water in a plastic cup, World Health • 47th Yeor, No. 1, January-February 1994 19 makes a fluoride solution with a concentration of 0.04% sodium fluoride. The cost of one packet was Rs 1.25 five years ago and Rs 4 (US$ 0.12) today. This pack is sufficient for a family offour (two adults and two children) to do a daily fluoride mouth rinse for a full month; the cost proved to be easily affordable by rural people. The community was advised to dissolve one fluoriwash tablet in a plastic cup with the help of a plastic spoon every night before retiring to bed. They should put one to one and a half teaspoonfuls of solution in the mouth of each family member, who should swish for two minutes and then spit. To have the maximum beneficial effect, they should go to sleep without further washing their mouth; in any case, they should not drink anything for at least two or three hours. As there are hardly any chemist's shops in the small villages oflndia, these packets· of fluoriwash tablets were made available to the community through the shops of ordinary traders selling groceries. Such low-cost preventive programmes, as described here, can be practised by families in the rural areas of any country where the use of a toothbrush and fluoride toothpaste would be too expensive. As to cleaning their teeth, these population groups could and do use tree twigs as chewing sticks in place of a toothbrush. • Prevention at a low cost Oral care is costly. Some rich countries spend 5% to l l% of their annual health budgets on oral health. It is a price that few Third World countries, if any, can afford to pay. Prevention rather than repair - and repair when problems do arise- are the real answers. It is estimated that prevention takes much less time and money than treatment and it is better! Oral health care personnel, such as "dental therapists" or "dental hygienists", can be trained in two to three years. They undertake oral health promotion and education. They also have the skills to clean teeth, remove tartar deposits, fill cavities and perform ordinary extractions. Dentists can then concentrate on more difficult treatment and carry the overall responsibility for oral health care programmes. There is a ratioof onedentistforevery l 000 population in several rich countries; but only one for over a million people in some poor nations. When proper mouth care, including prevention, is promoted, these ratios should improve significantly. Professor (Mrs) Amrit Tewari is Head of the Department of Dentistry, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 1600 12, India . . and shows the children how to rinse their mouths. Oral health, however, does not depend only on oral health care personnel.lt is first and foremost a personal and family responsibility. Children should be brought to a health worker trained in oral careasearlyas possible. They should learn very early about oral hygiene when they learn about body hygiene, preferably by two years of age. By six years, when the permanent teeth- the teeth for life - are growing, they should have established good oral habits. Parents should take the responsibility for cleaning children's teeth , up to the age of eight years. The experience of a number of industrialized countries has shown that the cavities dropped by about 80% in the la~_t 20 years as a result of a combination of preventive measures - including health education and information programmes advocating oral hygiene, the optimal use of fluorides, and "prudent" diets. Indeed, it can be said that cleaning teeth and gums, using fluorides, and eating fermentable co rbohyd rates w ith mea Is ra ther tho n between meals are the "pi lla rs of prevention".