Wake-up Call for Action

Why take Action?

We are aware that the Indian democracy is committed to the care and wellbeing of its citizens. The government’s long-term investment in science and technology has paid off by adding years to the average life span and enhancing the quality of life. But not all Indian have benefitted equally from improvements in oral health and health care.

India’s continued growth in diversity has resulted in a society with broad, educational, cultural, language and economic differences which hinder some individuals and groups from realizing the gains in oral health. National Oral Health Survey conducted in 2005 by Indian Dental Association highlighted dental disparities revealed silent epidemic of oral diseases affecting rural Indians -- our most vulnerable citizens. The survey found Dentist :Population ratio in the rural areas to be dismally low with less than 2% dentists being available for 72% of rural population. The grim reality in India is, that 95% of the population suffers from gum disease, only 50% use a toothbrush and just 2% of the population visit the dentist.

The survey sounded an alarm and the need to affirm once again that ---- oral health is very vital to general health and well-being.

IDA's immediate response was to address the ‘silent epidemic of oral diseases affecting the most vulnerable citizens of lowest strata young and old and under-privileged groups’ by initiating National Oral Health Programme which aims at optimal oral health by 2020.

Oral Diseases are Preventable

Good oral health is vital to good overall health. Poor oral health negatively affects growth, development, learning, nutrition, and communication, self-esteem for all sections of society, young and old ---- have and have-nots. India exposes disparities in oral health, with lower income groups having higher disease rates, limited or no access to care. IDA call-for-action accurately assesses needs, monitors outcomes, decreases disparities, improves access to care and ultimately improves oral health.

IDA affirms that oral health is essential to general health and well-being and thus the need to take action. IDA aims that

  • No body suffers from oral diseases which can be prevented and treated.
  • Young children do not from suffer caries.
  • Rural populations do not experience poor oral health due to barriers to access to care, shortage of resources and professional.

These actions crystallize IDA’s aim for optimal oral health for the nation. The association is confident that rewards in health and well-being can accrue for all Indians. However, a number of barriers hinder the ability of Indians from attaining optimal oral health calling for action-framework --- a national oral health plan to improve quality of life and eliminate oral health disparities.

IDA wants to create awareness about:
  • Oral health just being more than healthy teeth.
  • Oral diseases and disorders affect health and well-being throughout life.
  • The mouth reflects general health and well-being.
  • Oral diseases and conditions are associated with other health problems.
  • Lifestyle behaviours that affect general health (tobacco use, excessive alcohol use and poor dietary choices) affect oral and craniofacial health.
  • Safe and effective measures exist to prevent the most common dental diseases—dental caries and periodontal diseases.
  • There are profound and consequential oral health disparities in India.
  • Information is needed to improve India’s oral health and eliminate health disparities.
  • Scientific research is key to reduction in the burden of diseases and disorders that affect the face, mouth and teeth.
Reason for Action

Knowledge and tools of the 21st century provide a new window into the complex link between oral health and general health. Science is advancing rapidly and breakthroughs in oral, dental and craniofacial research proves that oral diseases, such as caries, periodontal disease, oral cancers and sports-related injuries of the craniofacial complex are all preventable.

We now have the perspective to understand health and disease. This deep insight enhances our ability to predict and more effectively manage many oral and dental diseases by improving community outreach, education and behavioural modification. We conclude that the morbidity, mortality and economic burden associated with these conditions can be considerably reduced by programmes and interventions aimed at prevention and health promotion.

The Burden of Oral Diseases

Oral diseases are progressive, cumulative and become more complex over time. They can affect our ability to eat, the foods we choose, how we look and the way we communicate. These diseases can affect economic productivity and compromise our ability to work at home, at school or on the job.

Healthy teeth help a child eat properly, speak clearly and guide adult teeth into place. Yet tooth decay is the most common chronic disease of childhood. Good oral health helps seniors get proper nutrition, maintain good overall health and enjoy a better quality of life. Many factors put older adults at risk for poor oral health, including medications and health conditions that cause “dry mouth” which can quickly lead to cavities and severe gum disease, a condition linked to other serious chronic health disorders, including diabetes, heart disease and stroke. Because older adults are more likely to experience a chronic health condition, maintaining good oral health becomes even more important with age.

The following are highlights of oral health data for children, adults, and the elderly.

Children

India has population of 440 million and 26 million children added annually
  • Cleft lip/palate, one of the most common birth defects.
  • Other birth defects such as hereditary ectodermal dysplasias, where all or most teeth are missing or misshapen, cause lifetime problems that can be devastating to children and adults.
  • Dental caries (tooth decay) is the most common chronic childhood disease – 5 times more common than asthma and 7 times more common than hay fever.
  • Over 80% under 15-year-have caries and 40% suffer from malocclusion.
  • There are striking disparities in dental disease by income. Poor children suffer twice as much dental caries as their more affluent peers and their disease is more likely to be untreated. These poor-non poor differences continue into adolescence.
  • Tobacco-related oral lesions are prevalent in adolescents who currently use smokeless (spit) tobacco.
  • Unintentional injuries, many of which include head, mouth and neck injuries, are common in children.
  • Intentional injuries commonly affect the craniofacial tissues.
  • Professional care is necessary for maintaining oral health.
  • The social impact of oral diseases in children is substantial as schools hours are lost each year to dental-related illness.
  • Pain and suffering due to untreated diseases can lead to problems in eating, speaking, and attending to learning.
Adults
  • 95% adults show signs of periodontal or gingival diseases.
  • Clinical symptoms of viral infections, such as herpes labialis (cold sores) and oral ulcers (canker sores) are common in adulthood as only 2% of the population visit a dentist.
  • Chronic disabling diseases such as temporomandibular disorders, Sjögren’s syndrome, diabetes and osteoporosis affects the oral health of Indians.
  • Need to increase awareness because 50% Indians don’t use a tooth brush.
  • Pain is a common symptom of craniofacial disorders and is accompanied by interference with vital functions such a eating, swallowing and speech.
  • Population growth as well as diagnostics that are enabling earlier detection of cancer means that more patients than ever before are undergoing cancer treatments.
  • Immunocompromised patients, such as those with HIV infection and those undergoing organ transplantation, are at higher risk for oral problems such as candidiasis.
  • Tobacco-related cancer is the most prevalent of cancers. Annually 1,30,000 people succumb to oral cancer, this translates into approx 14 deaths per hour in India.
Elderly
  • Elderly in 65- to 74-year-olds have severe periodontal disease.
  • About 30 percent of adults 65 years and older are edentulous. These figures are higher for those living in poverty.
  • Oral and pharyngeal cancers are primarily diagnosed in the elderly. Prognosis is poor.
  • Both prescription and over-the-counter drugs results in oral side effect – usually dry mouth. The inhibition of salivary flow increases the risk for oral disease because saliva contains antimicrobial components as well as minerals that can help rebuild tooth enamel after attack by acid-producing, decay-causing bacteria.
  • The inspiration behind this is to build a stronger, more effective and efficient oral health care system that would contribute to the health and well-being of all Indians. Initiatives by IDA enhance oral health and enlist the expertise of dental professions, individuals, health care providers, communities and policymakers at all levels of society.
Vision and Goals

The Vision of the Wake-up Call To Action is

  • For optimal oral health, acknowledging oral health is a fundamental part of general health and well-being
  • Engage in programmes to promote oral health and prevent disease.

The Goals of the Call To Action is to

  • Promote oral health.
  • Improve quality of life.
  • Eliminate oral health disparities

As a force for change to enhance the nation’s overall health and well-being, IDA urges that oral health promotion, disease prevention and oral health care have a presence in all health policy agendas set at local, state and national levels. For this to happen, the public, dental health professionals and government must understand that oral health is essential to general health and well-being at every stage of life. In addition, IDA seeks to act in efforts to address the nation’s overall health agenda.

The Actions

Action 1. Change perceptions of oral health

The perception ingrained in Indian mindset is that oral health is less important than and separate from general health. Activities to overcome these attitudes and beliefs are taken up at grassroots level which can lead to increased oral health literacy, understand basic oral and craniofacial information and services needed to make appropriate health decisions.

In this way, the prevention, early detection and management of diseases of the dental, oral, and craniofacial tissues can become integrated in health care. Formation of community-based programmes and social services will promote the general health and well-being of all Indians.

Change public perceptions
  • Enhance oral health literacy.
  • Develop messages that are culturally sensitive and linguistically competent.
  • Enhance knowledge of the value of regular, professional oral health care.
  • Increase the understanding of how the signs and symptoms of oral infections can indicate general health status and act as a barometer for other diseases.
Change policymakers’ perceptions
  • Inform government of the results of oral health research and programmes and of the oral health status.
  • Develop concise and relevant messages for government.
  • Develop concise and relevant messages for government.
  • Document the health and quality-of-life outcomes that result from the inclusion (or exclusion) of oral health services in programmes and reimbursement schedules.
Change dentists’ perceptions
  • Train dentists to conduct oral screenings as part of routine physical exams and make appropriate referrals.
  • Promote interdisciplinary training of dental personnel in counseling patients about how to reduce risk factors common to oral and general health.
  • Encourage dentist’s to refer patients to other health specialists as warranted by examinations and history.

Action 2. Undertake effective programmes

Reduce disease and disability.

Update the public and dental professionals on ways to reduce the burden of oral disease through education, behavioural change, risk reduction, early diagnosis and disease prevention management. Set criteria and strong foundations for evaluating the scientific evidence and promoting effective interventions.

Improve oral health care access.

Health disparities are commonly associated with populations whose access to health care services is extremely poor due to poverty, limited education or language skills, geographic isolation, age, gender, disability, or an existing medical condition. Establish close working relationships so that strategies tailored to the varying and continuing health needs can be developed.

Enhance health promotion and health literacy. To encourage healthier lifestyles and increase interventions for prevention or early detection of disease by changing the environment (the places where people work, play, learn or live).

Policies and programmes concerning tobacco cessation, dietary choices, wearing protective gear for sports and other lifestyle related efforts not only will benefit oral health, but are natural ways to integrate oral health promotion with promotion of general health and well-being.

Many Indians do not realize the importance of oral health and preventive measures that can be taken before a situation deteriorates affecting their oral health. Symptoms may not be recognized and treatment to overcome gets neglected thus oral health care programmes aim to:

Identify and reduce disease and disability

  • Implement science-based interventions appropriate for individuals and communities.
  • Enhance oral health-related content in health professions school curricula, residencies and continuing education programmes, by incorporating new findings on diagnosis, treatment and prevention of oral diseases and disorders.
  • Build and support epidemiologic and surveillance databases at national, state, and local levels to identify patterns of disease and populations at risk.
  • Data are needed on oral health status, disease and health services utilization and expenditures, sorted by demographic variables for various populations. Surveys should document baseline status, monitor progress and measure health outcomes.
  • Determine, at community or population levels, oral health care needs and system requirements, including appropriate reimbursement for services, facility and personnel needs, and mechanisms of referral.
  • Encourage partnerships among research, provider, and educational communities in activities, such as organizing workshops and conferences, to develop ways to meet the education, research, and service needs of patients who need special care and their families.
Improve access to oral health care
  • Promote and apply programmes that have demonstrated effective improvement in access to care.
  • Create an active and up-to-date database of these programmes.
  • Explore policy changes that can improve provider participation in public health insurance programmes and enhance patient access to care.
  • Remove barriers to the use of services by simplifying forms, letting individuals know when and how to obtain services and providing transportation and child care as needed.
  • Assist low-income patients in arranging and keeping oral health appointments.
  • Facilitate health insurance benefits for diseases and disorders affecting craniofacial, oral, and dental tissues, including genetic diseases such as the ectodermal dysplasias, congenital anomalies such as clefting syndromes, autoimmune diseases such as Sjögren’s syndrome, and chronic orofacial pain conditions such as temporomandibular disorders.
  • Ensure an adequate number and distribution of culturally competent providers to meet the needs of individuals and groups, particularly in health-care shortage areas.
  • Make optimal use of oral health and other health care providers in improving access to oral health care.
  • Energize and empower the public to implement solutions to meet their oral health care needs
  • Develop integrated and comprehensive care programmes that include oral health care and increase the number and types of settings in which oral health services are provided.

Action 3. Build the science base and accelerate science transfer

Advances in health depend on biomedical and behavioral research aimed at understanding the causes and pathological processes of diseases. This can lead to interventions that will improve prevention, diagnosis and treatment. Too many people outside the oral health community are uninformed about, misinformed about or simply not interested in oral health. Such lack of understanding and indifference may explain why community programmes fall short of full implementation, even though the scientific evidence for their effectiveness has been known for some time.

Biomedical and behavioral research in the 21st century will provide the knowledge base for an ever evolving health care practice. This scientific underpinning requires the support of the full range of research from basic studies to large-scale clinical trials. To achieve a balanced science portfolio it is essential to expand clinical studies, especially the study of complex oral diseases that involve the interactions of genetic, behavioural, and environmental factors.

Oral health research must also pursue research on chronic oral infections associated with heart and lung disease, diabetes, and premature low birth-weight babies. Such research must be complemented by prevention and behavioural science research (including community-based approaches and ways to change risk behaviour), health services research to explore how the structure and function of health care services affect health outcomes and by population health and epidemiology research to understand potential associations among diseases and possible risk factors. No one can foresee the findings from genetic studies in the years ahead but without question these advances will profoundly affect health, even indicating an individual’s susceptibility to major diseases and disorders.

Hybrid sciences of importance to oral health are also on the rise. For example, bio-engineering studies are establishing the basis for repair and regeneration of the body’s tissues and organs—including teeth, bones, and joints-- and ultimately full restoration of function. Oral diagnostics, using saliva or oral tissue samples, will contribute to overall health surveillance and monitoring.

If the public and their care providers are to benefit from research, efforts are needed to transfer new oral knowledge into improved means of diagnosis, treatment, and prevention. The public needs to be informed, accurately and often, of findings that affect their health. They need clear descriptions of the results from research and demonstration projects concerning lifestyle behaviors and disease prevention practices. At the same time, research is needed to determine the effect of oral health literacy on oral health.

Communities and organizations must also be able to reap the benefits of scientific advances, which may contribute to changes in the reimbursement and delivery of services, as well as enhance knowledge of risk factors. Advances in science and technology also mean that life-long learning for practitioners is essential, as is open lines of communication among laboratory scientists, clinicians and the academic faculties that design the curricula, write the textbooks, and teach the classes that prepare the next generation of health care providers.

Implementation strategies to build a balanced science base and accelerate science transfer should benefit all consumers, especially those in poorest oral health or at greatest risk.

Specifically there is a need to:
  • Enhance applied research (clinical and population-based studies, demonstration projects, health services research) to improve oral health and prevent disease.
  • Expand intervention studies aimed at preventing and managing oral infections and complex diseases, including new approaches to prevent dental caries and periodontal diseases.
  • Intensify population-based studies aimed at the prevention of oral cancer and oral-facial trauma.
  • Conduct studies to elucidate potential underlying mechanisms and determine any causal associations between oral infections and systemic conditions. If associations are demonstrated, test interventions to prevent or lower risk of complications.
  • Develop diagnostic markers for disease susceptibility and progression of oral diseases.
  • Develop and test diagnostic codes for oral diseases that can be used in research and in practice.
  • Investigate risk assessment approaches for individuals and communities, and translate them into optimal prevention, diagnosis, and treatment measures.
  • Develop biologic measures of disease and health that can be used as outcome variables and applied in epidemiologic studies and clinical trials.
  • Develop reliable and valid measures of patients’ oral health outcomes for use in programmes and in practice.
  • Support research on the effectiveness of community-based and clinical interventions.
  • Facilitate collaborations among health professional schools, state health programs, patient groups, professional associations, private practitioners, industries, and communities to support the conduct of clinical and community-based research as well as accelerate science transfer.
Accelerate the effective transfer of science into public health and private practice
  • Promote effective disease prevention measures that are underutilized.
  • Routinely transfer oral health research findings to health professional school curricula and continuing education programmes and incorporate appropriate curricula from other health professions- medical, nursing, pharmacy and social work--into dental education.
  • Communicate research findings to the public, clearly describing behaviours and actions that promote health and well-being.
  • Explore ways to accelerate the transfer of research findings into delivery systems, including appropriate changes in reimbursement for care.
  • Routinely evaluate the scientific evidence and update care recommendations.

Action 4. Increase oral health workforce’s capacity and flexibility

Meet patient needs. The patient pool of any health care provider tends to mirror the provider’s own racial and ethnic background. As such, the provider can play a catalytic role as a community spokesperson, addressing key health problems and service needs. While the number of women engaged in the health professions is increasing, the number of underrepresented racial and ethnic minorities is decreasing and remains limited. Specific racial and ethnic groups are underrepresented in the active dental profession compared to their representation in the general population:

Efforts require full community participation, mentorship and creative outreach. Enhance oral health workforce capacity. The lack of progress in supplying dental health professional shortage areas with needed professional personnel underscores the need for attention to the distribution of care providers, as well as the overall capacity of the collective workforce to meet the anticipated demand for oral health care as public understanding of its importance increases. Dental school recruitment programmes offer incentives to students who may want to return to practice in rural areas and inner cities are in a prime position to act. Through these programmes dental schools increase the diversity of the oral health workforce. To effect change in oral health workforce capacity, more training and recruitment efforts are needed. The lack of personnel with oral health expertise at all levels in public health programmes remains a serious problem, as does the projected unmet oral health faculty and researcher needs.

Currently, there is an acknowledged crisis in the ability to recruit faculty to dental schools and to attract clinicians into research careers. Dental school faculty and oral health researchers are needed to address the various scientific challenges and opportunities oral health presents, and to help transfer emerging knowledge to the next generation of health care providers. The lack of trained professionals ultimately results in a loss in the public’s health. Efforts are underway to address these needs, but the rate of recruitment and retention is slow.

Further, all health care professionals, whether trained at privately or publicly supported medical, dental, or allied health professional schools, need to be enlisted in local efforts to eliminate health disparities. These activities could include participating in part-time service in community clinics or in health care shortage areas, assisting in community-health assessment activities, participating in school-based disease prevention efforts and volunteering in health-promotion and disease-prevention efforts such as tobacco cessation programmes.

Efforts are needed to:
  • Change the racial and ethnic composition of the workforce to meet patient and community needs.
  • Document the outcomes of existing efforts to diversify the workforce in practice, education, and research.
  • Develop ways to expand and build upon successful recruitment and retention programmes.
  • Create and support programs that inform and encourage individuals to pursue health and science career options in high school and during graduate years.
Ensure a sufficient workforce pool to meet health care needs by
  • Expand scholarships and loan repayment efforts at all levels.
  • Specify and identify resources for conducting outreach and recruitment.
  • Develop mentoring programmes to ensure retention of individuals who have been successfully recruited into oral health careers.
  • Facilitate collaborations among professional, government, academic, industry, community organizations and other institutions that are addressing the needs of the oral health workforce.
  • Provide training in communication skills and cultural competence to health care providers and students.

Secure an adequate and flexible workforce by

  • Assess the existing capacity and distribution of the oral health workforce.
  • Study how to extend or expand workforce capacity and productivity to address oral health in health care shortage areas.
  • Work to ensure oral health expertise is available to health departments and to government programmes.

Action 5. Increase Collaborations

The private sector and public sector each has unique characteristics and strengths. Linking the two can result in a creative synergy capitalizing on the talent and resources of each partner. In addition, efforts are needed within each sector to increase the capacity for programme development, for building partnerships, and for leveraging programmes.

A sustained effort is needed right now to build the nation’s oral health infrastructure to ensure that all sectors of society--the public, private practitioners, and government personnel--have sufficient knowledge, expertise, and resources to design, implement and monitor oral health programmes. Leadership for successfully directing and guiding public agency oral health units is essential. Further, incentives must be in place for partnerships to form and flourish. Disease prevention and health promotion campaigns and programmes that affect oral and general health-- such as tobacco control, diet counseling, health education aimed at pregnant women and new mothers and support for use of oral facial protection for sports—can benefit from collaborations among public health and health care practicing communities.

Programmes require the combined efforts of social service, education and health care services at state and local levels. Most importantly, the public in the form of voluntary organizations, community groups, or as individuals, must be included in any partnership that addresses oral and general health.

Successful partnering at all levels of society will require efforts to

  • Strengthen the networking capacity of individuals and communities to address their oral health needs.
  • Build and nurture broad-based coalitions that incorporate views and expertise of all stakeholders and that are tailored to specific populations, conditions or programmes.
  • Strengthen collaborations among dental, medical and public health communities for research, education, care delivery, and policy development.
  • Develop partnerships that are community-based, cross-disciplinary, and culturally sensitive.
  • Work with the Partnership Network and other coalitions to address the four actions previously described: change perceptions, overcome barriers, build a balanced science base, and increase oral health workforce diversity, capacity and flexibility.

This action plan will serve as a blueprint, one that can be a tool for enlisting collaborators and partners. Building this plan into existing health programmes will maximize the integration of oral health into general health programmes—not only by incorporating the expertise of multidisciplinary professional teams, but also allowing the plan to benefit from economies of scale by adding on to existing facilities, utilizing existing data and management systems and serve the public.

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