BASIC PACKAGE FOR ORAL CARE: A STEP TOWARDS PRIMARY ORAL HEALTH CARE

Abstract

Oral health remains a luxury for most of the world’s population. This is especially true for the disadvantaged irrespective of whether they live in some of the worlds most wealthy or the world’s poorest countries. Oral health problems remain a global problem and therefore must be a global concern. The Basic Package of Oral Health Care (BPOC), as presented in this report, represents a fusion of concepts and approaches that have developed over the last decade. In presenting this package, great emphasis has been placed on approaches with proven effectiveness and that are acceptable, feasible and affordable for most disadvantaged communities. The Basic Package of Oral Care (BPOC) places great emphasis on approaches which are acceptable, feasible and affordable and can be provided within the framework of the existing first line care, the primary health care system. Oral Urgent Treatment (OUT), Affordable Fluoride Toothpastes (AFT), Atraumatic Restorative Treatment (ART). Role of NGOs in implementing the Basic Package of Oral Care, Role of local dentists and dentist as a volunteer in a foreign country, Role of Oral care and Primary Health Care (PHC), Role of public private partnership. The implementation of the three components of the BPOC depends on prevailing local factors, including available human and financial resources, existing infrastructures, local perceived needs, treatment demands of the community, their leaders and dental association

Full text

TMU J. Dent Vol. 1; Issue 2 Apr – June 2014 |
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BASIC PACKAGE FOR ORAL CARE: A STEP TOWARDS PRIMARY ORAL
HEALTH CARE
Manu Batra, 1 Yogesh Chand Rajwar, 2 Nimish Agarwal, 3 Arjun Singh, 4 Manas Dutt, 5 Abhishek Sinha 6
Assistant Professor, 1 Assistant Professor, 2 Assistant Professor, 3 Assistant Professor, 4 Assistant Professor, 5 Assistant Professor,6
1. Department of Public Health Dentistry, Eklavya dental College and Hospital, Kotputli, Rajasthan.
2. Department of Oral Pathology & Microbiology, Teerthanker Mahaveer Dental College & Research Center, Moradabad.
3. Department of Oral & Maxillofacial Surgery, Kothiwal Dental College & Research Centre, Moradabad, Uttar Pradesh
4. Department of Prosthodontics, Kothiwal Dental College & Research Centre, Moradabad, Uttar Pradesh
5. Department of Oral & Maxillofacial Surgery, Kothiwal Dental College & Research Centre, Moradabad, Uttar Pradesh
6. Department of Periodontics, Azamgarh Dental College, Azamgarh, Uttar Pradesh, India
Introduction
More than 70% of the world’s population, mainly those
living in low- and middle income countries, have little or no
access to oral health care. Although oral health is
recognised as a basic human right, the lack of appropriate
and affordable oral care to more than 4 billion people
worldwide does not result in a massive increase of political
activity and financial resources to address the problem.1
India is one of the developing country where health sector
has improved a lot in recent decades but the disturbing fact
is that only 25% of India’s specialist physicians reside in
semi-urban areas, and a mere 3% live in rural areas.2 As a
result, rural areas, with a population approaching 700
million, continue to be deprived of proper healthcare
facilities. The people residing in rural India are deprived of
health care facilities, are unaware and illiterate.
Unsurprisingly, standards of oral health are very poor in
India, with a large proportion of the population affected by
conditions such as gum diseases and tooth decay; in
addition to this, two thirds of people have never seen a
dentist. There is an urgent need for an effective oral health
program meant for the rural community.
The Basic Package of Oral Care (BPOC) developed by the
WHO Collaborating Centre in Nijmegen, describes a
package of basic oral care activities which can be provided
within the framework of the existing first line care, the
Primary Health Care System.3
Oral Care and Primary Health Care (PHC)
More than 25 years ago, the Alma – Ata conference,
organised by the WHO and UNICEF, gave for the first time
priority to local, simple curative and preventive care
addressing the needs of the population; in contrast to
expensive western-oriented health care which remains
largely restricted to hospitals and private clinics.4
Delegating tasks to auxiliaries in Community Health
Centres and using simple but effective approaches are
important components of primary health care. During the
last few decades, PHC has been the basis of health care in
many low and middle-income countries. In dentistry
however, this change has not been actively pursued, but for
a few exceptions. Oral health care remains largely the
domain of dentists in private clinics and hospitals in urban
areas. Simple oral health care, combined with information
and preventive activities for the majority of poor and
disadvantaged populations, delivered by assistants or health
care workers in the community, rarely became a reality.
Some of the reasons for the huge gap in oral health status
and availability of oral health care are:
1. Low priority for oral health in relation to other
diseases;
2. Lack of professional and political advocacy for
oral health and for redistributing resources;
3. Absence of living conditions and health
determinants conducive to good oral health;
4. Dominance of the restorative approach and
western treatment and education models as = well
as inadequate workforce planning;
5. Lack of integration of oral care into PHC;
6. Resistance of the dental profession to delegate
tasks to non-dental personnel together with failure
to address the problems of quackery;
Abstract
Oral health remains a luxury for most of the world’s population. This is especially true for the disadvantaged
irrespective of whether they live in some of the worlds most wealthy or the world’s poorest countries. Oral health
problems remain a global problem and therefore must be a global concern. The Basic Package of Oral Health Care
(BPOC), as presented in this report, represents a fusion of concepts and approaches that have developed over the last
decade. In presenting this package, great emphasis has been placed on approaches with proven effectiveness and that
are acceptable, feasible and affordable for most disadvantaged communities. The Basic Package of Oral Care (BPOC)
places great emphasis on approaches which are acceptable, feasible and affordable and can be provided within the
framework of the existing first line care, the primary health care system. Oral Urgent Treatment (OUT), Affordable
Fluoride Toothpastes (AFT), Atraumatic Restorative Treatment (ART). Role of NGOs in implementing the Basic
Package of Oral Care, Role of local dentists and dentist as a volunteer in a foreign country, Role of Oral care and
Primary Health Care (PHC), Role of public private partnership. The implementation of the three components of the
BPOC depends on prevailing local factors, including available human and financial resources, existing infrastructures,
local perceived needs, treatment demands of the community, their leaders and dental association
Key Words: - Basic Packages of Oral Care, Fluoride, Oral Care
Review Article

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58
7. Services not based on community needs and
demands;5
The Basic Package of Oral Care (BPOC)
The Basic Package of Oral Care (BPOC) developed by the
WHO Collaborating Centre in Nijmegen, describes a
package of basic oral care activities which can be provided
within the framework of the existing first line care, the
Primary Health Care System. (BPOC)
Rationale of BPOC: - The situation in most non-EME
(non-established market economy) countries and in
disadvantaged communities in EME (established market
economy) countries calls for a change in approach.
Traditional western oral health care should be replaced by a
service that follows the principles of PHC. This implies that
more emphasis should be given to community-oriented
promotion of oral health.6
Components of BPOC 7
 Oral Urgent Treatment (OUT)
 Affordable Fluoride Toothpastes (AFT)
 Atraumatic Restorative Treatment (ART)
A] Oral Urgent Treatment (OUT) for the Emergency
Refers to management of oral pain, infections and trauma.
This discusses services targeted at the emergency relief of
oral pain, management of oral infection and dental trauma
through (OUT). An OUT service must be tailored to the
perceived needs and treatment demands of the local
population. The three fundamental elements of OUT
comprises of: -
 Relief of oral pain
 First aid for oral infections and dento-alveolar trauma
 Referral of complicated cases.
Although most oral diseases are not life threatening, but
still they constitute an important public health problem.
Their high prevalence, public demand for treatment, and
their impact on the individual and society in terms of pain,
discomfort, functional limitation and handicap affect the
quality of life. In addition, the social and financial impact
of oral diseases on the individual and community can be
very high.
Treatment Modalities (OUT)
 Extraction of badly decayed and severely periodontally
involved teeth under local anaesthesia.
 Treatment of post-extraction complications such as dry
sockets and bleeding.
 Drainage of localized oral abscesses.
 Palliative drug therapy for acute oral infections.
 First aid for dento-alveolar trauma.
Referring complicated cases to the nearest hospital. Oral
Urgent Treatment (OUT) is an on-demand service
providing basic emergency oral care. Relief of pain is the
predominant treatment demand of underserved populations.
Emergency oral care that is easily accessible for all should
be the first priority in any oral health programme.5
B] Affordable fluoride toothpaste (AFT)5 Affordable
Fluoride Toothpaste (AFT) is an efficient tool to create a
healthy and clean oral environment. The WHO states that
fluoride toothpaste is one of the most important delivery
systems for fluoride. The availability and affordability of
effective fluoride toothpaste is essential for every
preventive programme. Rationale for using Affordable
Fluoride Toothpaste (AFT).
 The anti-caries efficacy of fluoride toothpaste has been
proven in an extensive series of well-documented clinical
trials.
 The widespread and regular use of fluoride toothpaste in
non-EME countries would have an enormous beneficial
effect on the incidence of dental caries and periodontal
disease.
 Governments should recognize the enormous benefits of
fluoride toothpaste to oral health and should take the
responsibility to reduce or eliminate the tax burden on this
product.
Affordable fluoride toothpaste with anti-caries efficacy
should be made available to all to ensure that all
populations are exposed to adequate levels of fluoride by
the most appropriate, cost-effective and equitable means.
The packaging of the fluoride toothpastes should be clearly
labelled with the fluoride concentration and the descriptive
name of the fluoride compound. Advice for adult
supervision of tooth brushing by young children.
Production and expiration date should be labelled.
Instructions for using a pea-sized amount of paste by
children. Directions for proper rinsing after brushing should
be given. The Fluoride toothpaste that meets recommended
standards for efficacy should be tax-free and classified by
governments as a therapeutic agent rather than a cosmetic.
C] Atraumatic Restorative Treatment (ART)5 While
preventive methods, such as affordable fluoride toothpaste,
continue to make a large impact on the level of caries, some
carious lesions inevitably progress to cavitations. ART is a
novel approach to the management of dental caries that
involves no dental drill, plumbed water or electricity. The
ART approach is entirely consistent with modern concepts
of preventive and restorative oral care, which stress
maximum effort in prevention and minimal invasiveness of
oral tissues. Appropriately trained dental auxiliaries, such
as dental therapists, can perform ART at the lower level of
the health care pyramid such as in health centres and in
schools. This makes restorative treatment more affordable,
while simultaneously making it more available and
accessible. ART therefore meets the principles of PHC.
Effectiveness of the ART approach, survival of ART
restorations, ART restorations vs. conventional restorations
and the acceptability of ART restorations are some of the
issues to be considered prior to placement of ART
restorations. The ART approach is consistent with modern
concepts of preventive and minimally invasive restorative
oral care. ART is particularly suitable for school children

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and can be provided within a school dental care system. By
treating small cavities premature extractions are avoided.
Implementing the BPOC
1) Role of NGOs in implementing the Basic Package of
Oral Care The concept of the BPOC provides many
opportunities for NGOs to engage themselves in a
structured effort towards better oral health. Despite a
growing importance of non- governmental organisations
(NGO) in the medical and general health sector, which has
brought about a new generation of highly professional,
social responsible and financially transparent organisations,
the situation in the sector of oral health development
assistance is very different.8
Some of the drawbacks of this sector include:
 Financial resources for the majority of NGOs are very
limited,
 The degree of professionalism is generally very low (in
terms of organisation management, accountability,
volunteer training, evidence-based interventions, quality
control, evaluation and sustainability),
 Integration into existing local community structures is
often very low,
 Lack of coordination, information and technology sharing
between the different dental NGOs.
Although organisations and individuals involved are often
highly motivated and sacrifice significant amounts of time,
money and resources with the best of intentions, the impact
and sustainability of such volunteer engagement remains at
best very limited. Therefore, a profound strategic
reorientation for the majority of dental NGO’s and the
volunteers serving for them is long overdue. Their
programmes and projects need to be reoriented towards
projects that are efficient, sustainable and integrated and
accepted by host communities.5
2) Role of Local Dentists and Dentist as a Volunteer in a
Foreign Country There are a fairly large number of
dentists from the high-income world who are prepared to
volunteer to work in a low socio-economic community for a
limited period. Their motivations to volunteer may vary but
in most cases are rooted in the recognition of need and the
desire to help.2 They seek guidance from NGOs sending
volunteers or start projects on their own with the best of
intentions and undoubtedly praiseworthy motives. Patients
receiving medical assistance certainly benefit, but these
patients constitute only a small and almost insignificant
section of the whole population. The dentist can also train
the local health workers who can continue with the care
after the departure of the volunteer. Training packages in
form of videos can be created to train local health workers.
However, training of health workers in OUT is only
justified if there is a functioning Primary Health Care
system where the health worker can work with the acquired
OUT skills. There also needs to be referring network for
cases beyond the health worker’s capabilities. Once the
training is completed it is imperative for a local dentist, a
volunteer or an NGO to carry out regular evaluation visits.
These visits are needed to monitor the health worker’s
activities, the service performance and to make changes
where necessary. It is self-evident that only with a close co-
operation with local communities, government
administrations and other relevant organisations this type of
NGO and volunteer involvement is possible.8
3) Role of Oral care and Primary Health Care (PHC)
During the last few decades, PHC has been the basis of
health care in many low and middle-income countries. If
sufficient funds and manpower are available then primary
health care can be efficient ways to achieve the goal. Hence
there is a need to strengthen the health care centres at all
levels. The oral health care should be blended with the on-
going primary medical care.
4) Role of Public Private Partnership (PPP) Given strong
economic growth of country in past decade, increasing
demand for public investment across all sectors has created
investment gaps in these key sectors. In addition,
challenges are also increasing in terms of service delivery
standards, performance benchmarks, and incorporation of
technology into provision of health and education services
to all, especially poorest and those located far from urban
growth centres of country. Public- private partnerships or
PPPs have shown their ability to meet some of these
challenges in India. Public private partnership has been
identified as a key focus area for increasing access to health
services by integrating common people and local
government institutions. Public and Private sectors have
separate but complimentary roles recognized by health
sector which tried to make best use of their comparative
advantages.9 There is a need to identify areas of
collaboration of varied nature in PPP some of them are
awareness generation, health education, outsourcing of non-
health services. With respective strengths and weaknesses,
neither public sector nor private sector alone can operate in
best interest of health system.6
Conclusion
Presently, oral health is being given immense importance at
the national level. Most initiatives are aimed at the
prevention of oral disease, there is a need to look into
affordable and effective curative modalities too. Basic
Package of Oral Care can be a golden step in this direction.
The rural section of the community will be immensely
benefited and in turn the overall burden of oral diseases will
come down drastically. There is an utmost need for public
health dentists along with dentists in government service,
preferably with some training in public health to implement
BPOC at their respective areas and analyze the feasibility
and effectiveness of it in the community.
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Corresponding Address:
Dr. Manu Batra
Assistant Professor
Department Of Public Health Dentistry
Teerthankar Mahaveer Dental College
Delhi Road, Moradabad-244001, Uttar Pradesh, India
Email – drmanubatra@aol.com