BPOC Chapter1

Basic Package of Oral Care

Jo E. Frencken

Christopher J. Holmgren

Wim H. van Palenstein Helderman

WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios

Chapter 1 - Oral health priorities for the disadvantaged

This chapter describes the prevailing oral health problems among disadvantaged populations in both established and non-established market economies. Untreated oral diseases, inequalities in delivery systems and the absence of adequate community-

oriented preventive services characterize the current situation. There is an urgent need for a change toward an oral care system that meets the principles of primary health care (PHC).

A basic package of oral care (BPOC), which is available to all, aims at achieving the objectives of the PHC approach. The three components of the BPOC are 1) Oral Urgent Treatment (OUT); 2) Affordable Fluoride Toothpaste (AFT); and 3) Atraumatic Restorative Treatment (ART). Oral health promotion is considered an integral part of BPOC. Each region and country should develop its own BPOC based on the perceived needs of the local population and on existing supporting environmental conditions.

Introduction

Oral health problems exist for the disadvantaged both in non-established market economy (non-EME) and established market economy (EME) countries. The difficulties are particularly severe for many communities in non-EME countries, which often have little or no access to basic emergency treatment for oral pain and infections. In addition, these communities usually have no organized system for the prevention of oral diseases.

In non-EME countries as well as in pockets of deprivation in EME countries, the insufficiency of resources for oral health and the shortage of dentists are commonly considered the main barriers to future improvements. Increasing the number of dentists and stimulating individual-oriented oral health education (OHE) provided by dental professionals often are not feasible. An alternative, consisting of training primary health care workers to undertake elements of basic oral care and the integration of OHE into the primary health care system, is rarely available. Although oral health is often a low priority among decision-makers, most non-EME countries have public funds available for oral health care. The important question is how to utilize these funds appropriately to meet the most urgent needs. Governments do not always realize that there is a compelling need to develop basic oral health care systems against the background of limited funding, existing infrastructures and perceived needs and treatment demands of the population.

The primary health care approach

Governments in many countries have adopted the primary health care (PHC) approach in their national health care systems. PHC means redirecting the prevention and control of common diseases away from hospital-based care. PHC aims to provide basic curative and preventive care for all at a cost that the country and community can afford. Oral diseases, particularly dental caries with its early onset, are among the most common diseases. Therefore, oral care should be part of the PHC system. Unfortunately, oral care is inadequately integrated into the PHC systems in many countries.

There is currently no sustainable basic oral care service in PHC that can be universally adopted. Two main barriers prohibit proper inclusion of oral health care into the PHC system: dentistry's traditional orientation toward individual care rather than a community approach, and its inherent technical - rather than social and behavioral - character. The philosophy of conventional dentistry must change to one of low-technology treatment, control and prevention to meet the perceived oral health needs and treatment demands of the community.

National epidemiological data on the prevalence and severity of oral diseases are of limited use in planning for basic oral health care. The emphasis on professional normative epidemiological data on oral diseases and treatment needs has seriously distorted people's views on oral health and on determining priorities for establishing needed services. More meaningful indicators for the planning of basic oral care include information on the community characteristics,

people's habits and perceived oral health problems and needs as well as the existing infrastructures.

The emphasis on these indicators of need is crucial. In addition to the needs observed by the professional, it should reflect the perceived needs and wants of the consumer. This collaborative approach has a better chance of being integrated into the existing community health care structures. However, since many non-EME countries have insufficient resources to run even a rudimentary PHC system, proposals for a new oral health care strategy must be viewed in the wider context of the available PHC services.

The prevailing oral health situation

In many non-EME countries, the majority of 12-year-old children have untreated dental caries, with risk of pain, disfigurement and spreading infections. This condition can result in tooth loss at a relatively young age. Relief of pain is the predominant treatment demand of disadvantaged populations. Pain is mainly caused by oral infections, which in some cases can be life-threatening. People from disadvantaged communities do not visit clinics for preventive intervention or for restorative treatment to prevent loss of teeth. The standard of oral hygiene is usually low and knowledge and habits relating to oral health are often poor. Changes in attitude, leading to demands for more prevention-oriented treatment and changes in lifestyle conducive to good oral health, will take time. In such circumstances, oral health promotion (OHP) is the cornerstone of oral health self care. It is vital to the control and prevention of oral diseases in the future. Unfortunately, most populations in non-EME countries are not exposed to community-oriented OHP.

Oral health care in most rural and some urban areas in non-EME countries is difficult to obtain. If available, tooth extraction is the predominant mode of treatment. Oral care is usually conventional in nature with the emphasis on technical and curative solutions, which are expensive and an option only for the affluent sector of the population. This type of traditional dentistry overlooks the importance of community-oriented prevention, exemplified by the improvement in oral health in EME countries. The history of dentistry in EME countries demonstrates that merely increasing the number of dentists does not control dental caries. It was not until the acceptance of OHP and the introduction of mass preventive measures, particularly the provision of fluoride toothpaste, that the incidence of caries and gingivitis started to decline. Toothpaste, including fluoride toothpaste, is available in most countries. However, in many cases, the price is too high. Thus, situations may occur in which people want to use toothpaste (and toothbrushes), but cannot afford to do so.

Despite the general improvements in oral health achieved in EME countries, there are many people who have not benefited sufficiently from effective preventive and curative oral health services that are available. This is apparent in the excessive level of caries and the disproportionate treatment needs of the young, deprived and socially disadvantaged groups. This unfavorable situation is also seen in immigrant groups in many EME countries.

Rationale for the Basic Package of Oral Care (BPOC)

The situation in most non-EME countries and in disadvantaged communities in EME 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. Treatment that is affordable for governments and individuals should also receive more attention. Using this approach, the level of untreated dental disease will become manageable. A basic package of oral care (BPOC) aims to reach all people at a much lower cost than traditional oral health services.

The three components of BPOC are:

• Oral Urgent Treatment (OUT)

• Affordable Fluoride Toothpaste (AFT)

• Atraumatic Restorative Treatment (ART)

Oral health promotion forms an integral component of BPOC to heighten awareness of what is possible. The successful introduction of BPOC in a community relies to a large extent on good communication among all parties involved.

There is no single model suitable for universal application. Each region or country should develop its own BPOC based on the perceived needs of its population and on the utilization of existing health care structures. The latter point is crucial. Too many oral health programs have failed as a result of management, logistical and financial problems because they were organized apart from the existing PHC. The following chapters highlight the general principles behind the three components of BPOC and provide evidence of their effectiveness.