Cost-effective and proven prevention measures like fluoride present mankind with a unique opportunity to vastly reduce the global burden of dental caries – a burden which cumulatively probably causes more pain and suffering than any other health condition today. Unfortunately, this opportunity to date has not been taken. Whether it be due to the historic separation of dentistry from general medicine or the emphasis upon diseases causing direct mortality rather than primarily affecting quality of life, the oral health needs of middle and low-income countries have been consistently ignored by the large, experienced health and development NGOs. 

 

 

Sadly, in the absence of involvement by experienced health organisations and development NGOs, past efforts were led primarily by western dentists or dental universities, who, by the nature of their clinical training, were primarily concerned with curative rather than preventive solutions. Thus, instead of leading with preventive public health initiatives like fluoride, nearly all resources and efforts were ploughed into a “western” clinical approach to dental care, characterised by the training of dentists to operate from high-tech dental clinics and offering complex restorative treatments.

 

 

 

Today, even some of the poorest countries of the world have national dental schools, but are typically training only handfuls of dentists who could never meet the treatment needs of their entire populations. Most of these dentists once trained, are based in poorly resourced clinics in the main urban government or NGO hospitals. However, in these settings, they often actually see relatively few patients for a number of reasons:-

 

 

Firstly, because the bulk of populations live in outlying rural areas; Secondly, most potential patients cannot afford the fees charged to cover high clinic costs; Thirdly, and perhaps most crucially, there is not a culture of visiting the dentist. While there are many notable exceptions, it is not unusual in many countries for fully trained dentists in both government and NGO hospitals to be treating less than 5 patients a day. The pay is generally low and the dentists often become demoralised resulting in many of them leaving government and NGO employment to start private clinics serving just the richest professional communities in the main cities. Alternatively, they leave the country altogether. It is not unusual in some countries in Africa that more than half of dentists trained have left their homeland within two years of graduation, with their dental qualifications being a passport to better paid jobs in the West or other more developed nations.

 

In other countries, dentists develop alternative careers to supplement their incomes. This, coupled with small training capacities, mean that in some countries, (particularly in Africa), total numbers of dentists are negligible. In Ethiopia in 2005 for example, there were only 52 dentists for a population of 63 million people (WHO stats). 

 

                                          

Numerous research projects in recent years have unequivocally shown that this western clinical approach, despite being hugely expensive, is having an almost negligible effect on overall oral health in middle and low-income countries.

 

 

Therefore, over the last twenty years, a number of local, regional (and in a couple of cases national) oral health programmes have been introduced in middle and low-income countries, which have taken radically different approaches to oral health (link to case studies). Mainly led by tiny oral health NGOs, these have placed a heavier emphasis on preventive public health measures and a more primary healthcare approach to providing dental care, involving community based activities and utilising general health workers to provide basic dental services through lower-tech, cost-effective treatment techniques.

 

 

 

Some of these have been very successful and have produced tangible improvements in the oral health of whole populations as well as much wider access to safe and effective dental care for rural populations. Following this, some forward thinking governments also adopted some of these approaches and they too found them successful as well as being much more cost-effective, and an extensive body of evidence has now been collected to support these approaches.

 

 

 

 

 

 

As a result, these approaches are now widely accepted and advocated by most of the oral health development NGO community, and indeed, the World Health Organisation, who have endorsed some of these approaches and techniques in their “WHO Basic Package of Oral Care”. While it is accepted there is a need for some regional referral centres employing skilled dental professionals to treat complex cases, it is now commonly recognised that these must be in support of, rather than instead of, preventive public health measures and primary oral health care services.

 

 

Despite this, the disproportionate bias still given to the “western clinical” approach both in terms of funding and status by governments remains a major problem in most middle and low-income countries. In many cases, the entrenched structures and sometimes vested interests of dental schools (who are often also principle advisors to Ministries of Health on oral health policy), are barriers to implementing preventive public health programmes and a transition to a more primary health care approach to dental care. In addition, this is still undermined by well-meaning NGOs and individuals, who without background understanding of oral health development issues in middle and low-income countries, instinctively promote and encourage “western clinical” solutions.

 

 

However, today, as the effects and wider social consequences of dental caries and various oral diseases are being recognised, more and more governments and overseas-based NGOs are wanting to implement effective oral health programmes. The challenge now is to ensure they have the support and training necessary to channel their efforts into the right areas, centred around preventive public health measures and primary health care approaches to dental care provision.