Down in the mouth - An example from oral health

by Neil McDonald.

DENTAL Means 'of the teeth
ORAL Means 'of the mouth'

Nepal is one of the world’s ten poorest countries, with just $6 available from the government budget to provide healthcare for each person every year. The treatment of infectious diseases of the chest and bowels swallows all of this money. Who cares about teeth?

Our studies show that the rapid urbanisation taking place in most Third World countries produces more tooth decay because sugar-containing foods such as biscuits and carbonated drinks are so easily available.

In industrialised countries the traditional approach is to ‘go to the dentist’ when things go wrong. In Nepal 100 dentists serve 24 million people. What chance is there of finding dental care when you have serious toothache? If you live in Kathmandu, the capital, you may be lucky since 92 of the dentists work there, serving one million of the population. That leaves just eight dentists to care for the remaining 23 million…

The United Mission to Nepal Oral Health Programme (OHP) has developed a unique approach to addressing Nepal’s oral health needs by developing an ‘upstream’, ‘midstream’ and ‘downstream’ influence:

Upstream

(Research, networking and publishing to encourage policy changes)

• Studying the levels of dental disease in both rural and urban school children has given us a baseline for our work policy.
• Extensive studies have been made of Nepal’s drinking water over the last three years to determine the natural fluoride content (fluoride strengthens teeth and cuts dental decay by half). We discovered that only two out of 600 locations examined had naturally occurring recommended levels. Therefore…
• Local toothpaste companies and the Nepal Dental Association have been lobbied with the results of our research and have been encouraged to put the recommended fluoride levels in low cost toothpaste instead. A major multinational manufacturer has now responded. This public health measure will have more effect on dental decay than any other aspect of our work.

Relevant information has been widely published to inform the government, the dental profession and the public of the current situation.

Midstream

(Preventive dental healthcare)

Rural government healthposts are ideal sites for delivering appropriate dental healthcare at village level. The government paramedics who run these posts have now received ‘top-up’ training in disease prevention and simple pain relief. School visits are included and children are encouraged to check each other’s mouths. Trainees are visited regularly by their trainers and given on the- job refresher courses.

Literature with pictures is produced in the Nepali language. These ‘flashcards’ and posters are aimed at schoolteachers, parents and other adults in non-formal education classes who will use the information to teach children. The main subjects we cover include:

prevention of dental decay and gum disease through:

• good nutrition (including breastfeeding young children)
• regular brushing of teeth with a fluoride toothpaste.

prevention of oral cancer (South Asia has the highest rate in the world) through encouraging people to avoid or reduce their use of:

• smoking
• chewing tobacco – especially when combined with drinking alcohol
• chewing pan (a mixture of areca nut, lime, chewable tobacco and masala wrapped in a green betel leaf).

Downstream

(Curative care)

• All of our staff are either dentists or dental therapists. Wherever we work we always offer pain relief care to those in need. This particularly applies to schoolchildren who often have no opportunity to get help for their painful dental problems. Practical care also builds up more faith in our work with teachers, parents and villagers, who see that we use action as well as words. They are then likely to be helpful when we plan further visits to their community.
• People with more serious problems, who may need surgery or tooth repairs, are referred to one of our hospital dental departments where good care is available at modest cost.

As the ‘upstream’ and ‘midstream’ efforts begin to have their effect, the ‘downstream’ work should ideally become a safety net only and not the main focus. In practice, this is a long-term strategy with the aim of helping people take charge of their oral health condition. Our emphasis is heavily biased towards preventing dental disease.

Comments received during training sessions

‘I want to care for my patients and give them the best I can. This training has shown that somebody cares for me as well. Thank you!’

‘The people I serve make great demands on me each day. I’m not a doctor, just a rural paramedic. I feel better because I can help them with my new dental skills’.

‘Please can I come back in six months for a refresher course?’

‘I now plan to run a dental session each Tuesday morning in my healthpost.’ 

Neil McDonald has been the Director of the Oral Health Programme of the United Mission to Nepal for three years. This programme is supported by Tearfund. Neil has also worked for a number of years in Kenya and UK as a dentist. His address is: c/o UMN, PO Box 126, Kathmandu, Nepal.
Fax: + 977 1 225559 E-mail: [email protected]

Tek and Leena's stories

Feathers or forceps?

Tek Chhetri is a young man of 23 from Western Nepal. He supports himself by his work as a teacher in a primary school, two hours walk from his village near Tansen. His elderly parents depend upon his support, so his salary of $45 per month does not go far. Tek would like to marry a local girl but cannot afford to do so. He's trying to improve his situation by studying for a degree at the local college before going to work each day. The financial and work demands placed on him result in frequent ill-health.

A painful molar tooth had troubled him for many weeks. One morning he awoke to find his face swollen to the point where his right eye was closed and his mouth could barely open. In pain, he sought advice from the local faith healer who advised him to bring him twelve plump chickens. Tek borrowed the equivalent of half his monthly wage at high interest from a moneylender and bought the chickens. After the birds had been sacrificed, the faith healer placed a paperclip in Tek's earlobe and told him that all would be well.

The following day Tek was in a dreadful state. He had a raging fever and could hardly walk. Someone in the village suggested he visit the government health-post an hour away in the next valley. News had come that there was a paramedic there who had received basic dental training through the UMN Oral Health Programme. A friend helped Tek to get there and he was seen by the health worker who promptly removed the decayed tooth, free of charge. When he went back for a check-up a week later, Tek was a very happy man. ‘Next time you get a problem, bring your chickens to me!' said the paramedic.

Timely advice

Leena Khadka is an attractive 19 year-old girl. Her mother died when she was 10 years old and her father left home. Leena was brought up by other family members but to comfort herself began chewing pan (areca nut) which is a stimulant. After several years she began experiencing pain when opening her mouth. She also found that her mouth would not open as wide as before. She couldn't eat her favourite spicy foods and kept away from her friends because she couldn't smile without pain.

Leena thought she had mouth cancer and was so afraid that she didn't seek help until she was 17 years old. Her local healthpost paramedic had recently been trained by the UMN Oral Health Programme in the diagnosis and management of common mouth problems. He noticed small growths in Leena's cheeks which were the result of chewing pan. He advised Leena to stop her chewing habit – which she did with great difficulty. He also told her that cancer of the mouth could develop from her present problem but, by stopping now, the risk would be much less.

Leena wanted further help and the paramedic referred her to a UMN hospital where a dentist gave her counselling and mouth exercises. This helped to increase her mouth opening to an acceptable degree and improved her self-confidence. As a sign of this she even entered the Miss Nepal contest this year!

Confidence through appropriate training

Durga Adhikari has worked in a rural health-post for three years. His two years of paramedic training have equipped him to cope with most of the basic health needs presenting each day, with the exception of dental care. This used to worry him every time someone arrived in pain. He had no idea where to inject a local anaesthetic. His kit contained an old, rusty pair of dental extraction forceps which only fitted on lower back teeth. There was nowhere else to send people for care.

Durga received one month of intensive dental training from the UMN Oral Health Programme and is now able to treat simple cases confidently with his new kit. He refers complicated cases to a (distant) hospital. He had previously found it very stressful when trying to help people in pain. He had little idea of what had caused their disease and therefore found it difficult to offer advice. These frustrations had combined to make him feel disillusioned in his work through lack of support and opportunity for further education. He felt abandoned in his rural situation.

People like Durga (pictured below) are the foundation of healthcare in Nepal. UMN recognises this and targets them for training and support. Villagers who receive care are delighted to have help locally instead of many kilometres away. This is practical Christian witness – hope for the hopeless and healing for the sick.