Dental Health International Nederland
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

ISBN
© WHO Collaborating Centre, Nijmegen 2002
This document is not an official publication of the World Health Organization (WHO) and all rights are reserved by the WHOCC Nijmegen.
The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but may not be sold.

Acknowledgments 

We kindly acknowledge with sincere appreciation the contribution made by Dr. R. Duckworth (England) and Dr. G.J. van Rhenen (the Netherlands) in writing part of this monograph.
     During the writing, the authors consulted many authorities around the world, who gave freely of their time and advice. In particular, the authors wish to express their sincere gratitude to the following who reviewed and contributed to the content of the monograph: Dr. B. Mouatt (England), Prof. Dr. S. Poulsen (Denmark), Dr. D. Purdell-Lewis (England), Prof. Dr. A. Sheiham (England).
     Special thanks must also be given to those who assisted in the production of this monograph. These include Margaret Kavanagh, who corrected all the spelling and grammatical errors, and Kees Hakvoort, who skillfully designed the layout.
     We would like to thank the Government of the Netherlands, through its Ministry of Development Cooperation, for demonstrating its trust in the WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios in Nijmegen and in the Basic Package of Oral Care by financing the production cost of this monograph.

 Contents
Chapter 1 - Oral health priorities for the disadvantaged   
Chapter 2 - Oral Urgent Treatment (OUT) for the emergency management of oral pain, infection and trauma   
Chapter 3 - Affordable Fluoride Toothpaste (AFT) for the prevention of dental caries    
Chapter 4 - Atraumatic Restorative Treatment (ART) for the management of dental caries    
Chapter 5 - Personnel and equipment for OUT and ART   39
Chapter 6 - Recommendations for establishing and evaluating BPOC demonstration programs   
References   

Preamble 

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 world's 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 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 BPOC is regarded as an essential foundation to any oral health care provision in a country or community. Only once the foundations are well established should other oral health provisions be considered. Regrettably, this is often not the case, and as a result large sums of public money are spent on inappropriate and often ineffective facilities.
     The essential components of the BPOC: Oral Urgent Treatment (OUT), Affordable Fluoride Toothpastes (AFT), and Atraumatic Restorative Treatment (ART), are components that the Oral Health Unit of the World Health Organization has developed and promoted through partnerships with non-governmental organizations, academia and industry. It is a perfect example of how different partners working together for a common goal can advance the boundaries of oral health care.      

As an example, the dramatic decline in the level of caries in many Western countries over the past two decades was first recognized through an analysis of data in the WHO Global Oral Data Bank. This decline is believed to be largely the result of the increased use of fluoride toothpastes in such countries. Since poorer segments of the world's population are unable to afford toothpaste, WHO collaborated with industry to produce an effective and affordable fluoride toothpaste. After successful field trials in Indonesia, affordable fluoride toothpastes are now available to many more of the world's population than ever before.
     Another example is Atraumatic Restorative Treatment. The Oral Health Unit of the World Health Organization was one of the first to recognize the huge potential that the ART approach could offer for community-based oral care around the world. For this reason ART was presented at headquarters of the WHO in Geneva on World Health Day in 1994 to mark the beginning of the Year of Oral Health 1994/95. The WHO has continued to support ART in the form of the WHO ART Global Initiative 1998-2000. This has seen the global promotion of ART through education in the form of training packages and ART master classes, community demonstration projects and technical assistance.
     Now that the essential components of basic oral care have been combined into a well-defined package, the next and crucial step is to evaluate the package as a whole in different settings around the world. To make this possible WHO once again calls for partnership between government and non-governmental organizations, the health profession, the academic community and industry.
It is also inevitable that as technologies and approaches develop, the package will evolve to adopt those that are appropriate, affordable and scientifically proven to be effective. For this reason, there is a continued and essential need to continue research into areas that show potential.
     This report would not have been possible without the continued support of many around the world, in particular members of the WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios, College of Dental Science, Radboud University of Nijmegen, the Netherlands.
     Lastly, I would like to acknowledge the contribution of my predecessors, Dr. Gennady Pakhomov and the late Dr. David Barmes, who had both the imagination and courage to foster and support fledgling concepts and approaches. Their foresight has matured into the BPOC - an essential step for the improvement of oral health globally.

Prof. Dr. P.E. Petersen
Oral Health Unit, WHO
Geneva


 Foreword

Oral health is recognized as a fundamental contributor to general health. Oral health problems continue to affect people throughout the world. Although seldom life threatening, these problems adversely affect people's well being, quality of life and economic activities.
     Governments allocate budgets for oral services, but in many non-established market economies (non-EME) the budgets are very limited and the services are not always directed to those most in need. This leads to situations in which large segments of the population have limited or no access to oral health care, and hence continue to suffer.           

This situation calls for the establishment of oral health as a priority and for the implementation of the essential components of oral health care that are affordable within the prevailing health infrastructures of deprived communities.
     The Oral Health Unit of the World Health Organization charged the WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios in Nijmegen, the Netherlands, with the task of compiling a report on the establishment of priorities in oral health care for deprived communities based on proven and effective oral health measures.
The philosophy of Primary Health Care (PHC), with its leading principle of basic oral care for all and emphasis on prevention and affordable and sustainable services, was a guideline in writing this report. The basic assumption was that the services offered should primarily meet people's perceived needs and treatment demands. The second assumption was that periodontal diseases are not a major cause of tooth loss. Therefore, removing calculus by scaling tooth surfaces is not considered a priority. As the report focuses on oral health care within the context of PHC, the treatment of serious disorders, e.g., oral cancer, cleft lip and palate disorders, are also not addressed.
     The report outlines the basic premise behind the three key components that constitute the Basic Package of Oral Care (BPOC). These are: Oral Urgent Treatment (OUT), Affordable Fluoride Toothpaste (AFT) and Atraumatic Restorative Treatment (ART).
     It argues for community-oriented promotion of oral health and affordable and effective interventions. It suggests that the package should be financed predominantly by public funding and implemented by competently trained primary (oral) health care workers.
     This report is a policy document. It presents the rationale that eventually leads to priorities in basic oral care. It is intended as a call to action for policy makers (Chief Dental Officers and advocates of oral health care at the Ministry of Health) and for partners in the development of oral health care (Non-Government Organizations dental academia, and industry).

The report does not provide an overview of the specific content of each proposed component. Neither does it outline the tasks of various cadres of dental personnel, nor does it present a strategy for implementation. Although of great importance, these elements cannot be covered in one report. Each local situation demands tailor-made solutions with respect to the personnel involved, its content and extent of the services offered.
     This report strongly recommends the implementation of small-scale (demonstration) projects to assess the effectiveness and sustainability of the basic package of oral care under local conditions before introducing the BPOC on a wider scale. In this endeavor, NGOs and industry have an important role to play, particularly in the planning and evaluation stages. They should consider themselves partners to governments in working toward improved oral health for deprived communities.

Ass. Prof. Dr. Frans H. Mikx,
Director WHO Collaborating Centre for Oral
Health Care Planning and Future Scenarios