Indian Pediatrics 2002; 39:1001-1005 

National Oral Health Care Program

Dental caries is a public health problem in India with a prevalence as high as 60-80% in Indian children(1), a figure far more than asthma(2). Apart from this, about 30% of children suffer from malaligned teeth and jaws(3) affecting proper functioning of the dento-facial apparatus. Lack of awareness about dental diseases has resulted in gross neglect of oral health. There is no component of oral health in the present health care system. The grass-root level health workers and doctors do not have adequate knowledge about oral hygiene and prevention of oro-dental problems. All the above factors have resulted in poor oro-dental health of our population.

The National Oral Health Care Program was launched in 1999 to combat the ever increasing patient load and reduce the morbidity due to oro-dental problems in the country. The Directorate General of Health Services and Ministry of Health & Family Welfare, Government of India launched this primary preventive oral health care program focussed on primary prevention, which is most cost effective, appropriate and desirable.

Although the oro-dental problems may not be life threatening, they present with expensive treatment modalities. In addition, they can be prevented and controlled to a large extent by public education and motivation. It is therefore, essential that to combat oral diseases, preventive approach including health education and promotion be given prime importance. Since the etiology and prevention of dental caries and malocclusion are very simple, prevention seems to be the most practical approach. The need of the time is to develop an accessible, low-cost, sustainable primary preventive program using the existing health infrastructure and resources.

The main focus of National Oral Health Care Program is prevention through generation of awareness. Thus for this purpose, oral health education of the school children and public is the main strategy and use of IEC material for awareness generation is the major component of the oral health.

Dental caries (tooth decay), gum diseases, malocclusion of teeth and oral cancers are major health problems in our country. Although these may not be life threatening, yet they cause lot of morbidity, psychological stress and their treatment is expensive. However, they can be prevented and controlled to a large extent by public education and motivation.

Dental caries or tooth decay is a common disease of children as well as adults. It appears as a brown or black mark on the tooth, which on progression leads to formation of a hole in the tooth. During this time the child may complain of sensitivity to hot and cold, or sweet and sour drinks. At this stage it can be treated by filling of the tooth. If left untreated this dental caries may lead to involvement of the deepest part of tooth i.e. pulp, resulting in severe pain and dental abscess.

Dental caries commonly occur on chewing surface or the inter-dental surfaces in posterior teeth(5). The chewing surfaces of these teeth are wide with pits and fissures for easy retention of food debris and microbes.

When the children are fed with bottle for prolonged periods and at night, a special pattern of dental caries occurs(6). In this disease, there is fast destruction of upper front and lower back teeth sparing lower front teeth because they are covered with tongue during feeding. This particular pattern of dental decay is called as nursing bottle caries. This condition requires prompt treatment, otherwise it may lead to other problems.

The causation of dental caries in early childhood involves complex interaction between the bacteria present in mouth, food remnants specially carbohydrates and the tooth surface(7). The bacteria present in oral cavity form an invisible layer of plaque. The plaque is mainly composed of bacteria, salivary proteins, few cells and some bacterial products. When the food remnants, especially carbohydrates, come in contact with the bacteria in the plaque, fermentation begins, resulting in dissolution of tooth surface and dental caries.

The initial attack of bacterial acid is on the enamel. During this time this may appear as brownish or black discolouration of tooth. On progression, this converts into a cavity or a hole in the tooth. At this time the usual complaint is that the food gets impacted between the teeth. Further progression of this lesion leads to involvement of the dentine. During this time the child complains of sensitivity to heat and cold or sweet and sour things. If this is not treated, it may lead to involvement of pulp and subsequent abscess formation.

The earliest sign of gum inflammation is bleeding from margins of gum during brushing without any pain. The margin of gum appears red. If proper brushing is not done during this time, the diseases may progress. Sometimes the gum may recede exposing the tooth root. This condition is called as gum recession. If not treated, the disease may progress to involve surrounding bone leading to pocket formation around tooth, called as periodontitis or pyorrhea. At this time patient may complain of bleeding, itching sensation, dull constant ache, increased hot and cold sensitivity, food impaction, and even loose teeth. All these symptoms suggest a quick attention and need for professional help. If this disease is not treated, ultimately it may result in loss of teeth.

The gum diseases are also caused by plaque accumulation. The bacteria present in plaque form toxic substances that may cause inflammation of gums. If plaque is not removed regularly it may harden to form calculus (tartar). This tartar further causes deposition of more bacteria and itself, as an irritant to gums, is responsible for inflammation.

Malocclusion is the second commonest dental disorder in children and young adults, next to dental caries. There are only a few studies available on the prevalence of malocclusion and orthodontic treatment needs in India. The isolated studies carried out in Punjab, Delhi, Trivandrum and Bangalore suggest that about 30% school going children suffer from some degree of malocclusion and half of these require comprehensive orthodontic treatment. However a large number of malocclusions are preventable.

Since the causes of dental caries and gum diseases are similar, following preventive and interceptive strategies are recommended for the control of these problems.

Instructions regarding oral hygiene of the infant and children should be given to mothers. After feeding, gum pads should be cleaned with a soft, clean cloth wrapped on a finger. Brushing should be started as soon as teeth erupt with a small baby brush. Parents should brush the child’s teeth till the age of four years and then supervised brushing should be encouraged. Use of fluoridated tooth paste should be recommended. Teeth should be brushed twice a day – in the morning after breakfast and at night before going to bed. In addition, teeth should preferably be brushed after eating any sweet and sticky food items. After every meal, the mouth should be rinsed with water and gums massaged with a finger.

Since intake of sweets is directly related to dental caries, it is recommended that total amount of sweets or carbohydrate rich food should be restricted(8). Frequency of eating snacks in between meals should be reduced. Snacks should be chosen wisely. Instead of eating sandwiches and pastries, which are soft and sticky, snacks containing cheese (paneer), nuts (ground-nuts), corn, fruits or salads should be encouraged. These food items are not only low in sugar, but have definite anti-caries effect. Detergent foods like raw vegetables and fruits have added advantages of stimulating salivation, which in itself has anti-caries properties. Sweet, aerated drinks also cause increased caries and therefore their consumption should be reduced.

Since diet during pregnancy directly influences formation of sound, caries resistant teeth, diet counselling should be given to expectant mothers. Diet containing adequate amount of protein, vitamin A,C and D, iron, calcium and phosphate should be given to expectant mothers and to all children during the formative stage of teeth, i.e., till the age of 12-14 years. Special instructions on breast feeding and proper choice and timing of bottle feed should be given to prevent nursing bottle caries and malocclusion. Breast feeding should be encouraged, but feeding -on-demand should be restricted. Bottle-feeding should be weaned by the age of one year. Bottle-feeding at night should be strictly avoided as it causes rampant tooth decay. Some infants are given comforters dipped in honey to prevent them from crying. Such a practice is harmful, as honey contains high amounts of sugar, and contact for long periods can cause tooth decay. Instructions regarding oral hygiene of the infant should be given in Well-Baby clinics and importance of nutrition should be emphasized in development of dentition.

Nursery and primary section children should be taught correct technique of brushing, mouth rinsing and gum massaging through live demonstration, role-playing and active participation. Not only children enjoy such methods of active learning but also the practices learnt at tender age would inculcate sound oral hygiene practices in them for rest of their lives. It would go a long way in reducing caries prevalence in children and adolescents. Importance of milk teeth as space maintainers for permanent teeth and in development of speech besides other functions such as mastication, esthetics and psychological well being, should be stressed while training the medical, para-medical personnel, school teachers and parents. Intensive Dental Health Care Program for school children should be implemented. In schools, it is observed that on birthdays, sweets and chocolates are distributed amongst children. Teachers should recommend to the parents to distribute stationary items instead of sweets. Teachers should also educate parents about the oral health care. School based oral health care programms should inculcate good dietary and oral hygiene practices in children. School books, of classes III, V and VIII should have a chapter on oral health. Older children of Class VIII to XII should be educated regarding harmful effects of all oral abusive habits and their consequences.

Schools should avoid carbohydrate rich foods in their mid-day meal program. School canteens should make caries protective foods available in their canteens such as items made out of cheese, cottage cheese (paneer), nuts (ground nuts), fruits, green salads, etc. As far as possible, all pediatric syrups should use non-caloric sweeteners. Manufacturers of jam, marmalade, syrups, drinks etc. should be encouraged to replace sucrose with sugar substitute sweeteners. Chewing gums with xylitol (sugar free) should be manufactured in India and made available at low cost as caries preventive measure.

Role of fluoride in caries prevention is well established. Use of topical fluoride in the form of fluoridated toothpaste is shown to reduce dental caries(9,10) by 30%. Its advantage is that it can be used at home and does not require professional supervision. Its use is recommended in all adults and in children above the age of 6 years, since younger children may swallow some of the paste and may develop systemic toxicity(11,12). Till 8 years of age, its use is recommended under the supervision of parents. This is one of the easiest methods of caries prevention. Its use should be recommended in community oral health care programms and it should also be made available at low cost by reducing taxes. Mouth-rinses containing 0.05% sodium fluoride has been proved to be highly effective in reducing caries(13) in children but should be used cautiously since ingestion of the mouth rinse may be harmful and can lead to dental flourosis. The International Dental Federation recommends use of fluoride mouthwash for children above the age of 6 years(11).

Prevention and early intervention is more fruitful than comprehensive treatment in cases of malocclusion. Therefore malocclusion requires immediate attention and professional advice. Harmful oral habits of mouth breathing and thumb or finger sucking should be discouraged and controlled. Early loss or over-retained milk teeth should be prevented and/or intercepted.

The right knowledge about the etiology and methods of prevention of oro-dental problems will not only help you but also your patients in getting the right treatment at the right time. Bottle feeding for prolonged periods and at night is criminal for the dentition of young children. Mind you, I am using the term criminal because early decay of most of the teeth has detrimental effect not only on child’s nutrition and development but also has a great aesthetic and psychological impact. Early loss of milk teeth can lead to development of malocclusion resulting in further complications in function, speech and aesthetics.

 References

1. Damle SG. Epidemiology of Dental Caries in India. In: Pediatric Dentistry. Arya Publishing House, New Delhi, 2002; pp 75-96.

2. Britton JR, Lewis SA. Epidemiology of childhood asthma. In: Asthma: Epidemiology, anti-inflammatory therapy and future trends. Eds Giembycz MA, O’Connor BJ. Birkhauser Verlag, Switzerland, 2000; pp 25-56.

3. Global Oral Data Bank. World Health Organization, Geneva 2001.

4. National Oral Health Care Programme: Implementation strategies. Directorate General of Health Services and Ministry of Health and Family Welfare, Government of India, 2001.

5. Harris R. Biology of children of Hopewood House, Bowral, Australia. Observations on dental caries experience extending over 5 years (1957-1961). J Dent Res 1963; 47: 1387-1399.

6. Erickson PR, Nickman JD. Early childhood caries: etiology, risk assessment and prevention. Northwest Dent 1999. 78: 27-32.

7. Rugg-Gunn AJ. Nutrition, diet and oral health. J R Coll Surg Edinb, 2001; 46: 320-328.

8. Tinanoff N, Palmer CA. Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000; 60: 197-206.

9. Bibby BG. Test of the effect of fluoride containing dentifrices on dental caries. J Dent Res 1945; 24: 297-303.

10. Koch G. Long term study of effect of supervised tooth brushing with sodium fluoride dentifrices. Caries Res 1970; 4: 149-157.

11. Sheen S, Pontefract H, Moran J. The benefits of toothpaste–real or imagined? The effectiveness of toothpaste in the control of plaque, gingivitis, periodontitis, calculus and oral malodour. Dent Update 2001; 28: 144-147.

12. Heifetz H, Horowitz HS. The amount of fluoride in current fluoride therapies: Safety consideration for children. J Dent Child 1984; 51: 257-269.

13. Ripa LW, Reske GS, Sposato AL, Rebich T. Supervised weekly rinsing with 0.2% neutral NaF solution: Results after 5 years. Comm Dental Oral Epidem 1983; 14: 1-6.